For this discussion, you will create a video post demonstrating a hand-off report. Watch this video to see how to create a video post: Creating a video post (Links to an external site.).
Communication with other healthcare professionals about a patient should be organized, clear and concise in order to best facilitate quality care for the patient. When giving hand-off communication or addressing status changes for your patient, you should follow a process of communication. Review the guidelines below for ISBARR, a communication tool widely used in healthcare settings for hand-off and status change communication.
Prior to calling the health care provider, follow these steps:
Have I seen and assessed the patient myself before calling?
Has the situation been discussed with the Nursing Coordinator or RRT?
Review the chart for the appropriate physician to call.
Know the admitting diagnosis and date of admission.
Have I read the most recent MD progress notes and notes from the nurse who worked the shift ahead of me?
Have available the following when speaking with the physician:
Patient’s chart
List of current medications, allergies, IV fluids, and labs
Most recent vital signs
Reporting laboratory results: provide the date and time test was done and results of previous tests for comparison
Code status
When calling the physician, follow the ISBARR process:
(I) Identification
(S) Situation: What is the situation you are calling about? Identify self, unit, patient, room number.
Briefly state the problem, what is it, when it happened or started, and how severe.
(B) Background: Pertinent background information related to the situation could include the following:
The admitting diagnosis and date of admission.
List of current medications, allergies, IV fluids, and labs.
Most recent vital signs.
Laboratory results: provide the date and time test was done and results of previous tests for comparison.
Other clinical information.
Code status
(A) Assessment: What is the nurse’s assessment of the situation?
(R) Recommendation: What is the nurse’s recommendation or what does he/she want?
Examples: Notification that patient has been admitted
Patient needs to be seen now o Order change
(R) Read Back: Document the change in the patient’s condition and health care provided
This might be a useful tool ISBARR_Week 8.docx
