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Verbal Handoff Assessment – Single
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Verbal Handoff Assessment – Single
Verbal Handoff Assessment – Single
2017-03-02T15:41:09+00:00
Verbal Handoff Assessment (SINGLE patient)
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" indicates required fields
Hospital or Location
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Santa Clara Valley Medical Center
Department or Service
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Obstetrics & Gynecology
Provider Type of Individual Giving Handoff
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Resident Physician
Attending Physician
Day of Week
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Weekday
Weekend
Time of Day
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AM
PM
Transition of Care Type (If this is a change in the phase of care, please indicate "transfer").
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Shift Change
Transfer
Where Did the Handoff Occur?
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Entirely in the patient room
Not entirely in the patient room
Not applicable
Other
Other
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Verbal Handoff Assessment Tool-Single
Indicate whether or not each element of the mnemonic is present. For transfer handoffs that are conducted over the phone, please ask the clinician giving handoff whether or not the receiver performed the synthesis.
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No
Yes
I. Illness Severity
P. Patient Summary
A. Action List
S. Situation Awareness/Contingency Planning
S. Synthesis by Receiver
I. Illness Severity: Identification as stable, "watcher", or unstable; must occur at the beginning of each patient handoff.
P. Patient Summary: Might include summary statement, events leading up to admission, hospital course, ongoing assessment, plan.
A. Action list: To do list; (must be separated from patient summary).
S. Situation Awareness/Contingency Planning: Know what’s going on; plan for what might happen.
S. Synthesis by Receiver: Written reminder to prompt receiver to summarize what was heard during verbal handoff.
Indicate whether or not the following elements were present in the observed handoff. For transfer handoffs that are conducted over the phone, please ask the clinician giving handoff whether the receiver exhibited a quality synthesis as outlined below.
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No
Yes
Giver actively engaged with receiver to ensure understanding of patients
Giver appropriately prioritized key information, concerns, or actions
Provided to-do list restricted to items that need to be accomplished on next shift
Used high quality contingency plans with clear if/then format
Receiver provided a synthesis that summarized the key components of the handoff, rather than restating all information
Was an I-PASS Written Handoff Tool used to facilitate the verbal handoff process?
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Yes
No
How would you rate the overall quality of the written handoff tool?
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Excellent – The tool is clear, complete, up to date, and highly useful for ensuring safe and effective handoffs
Good – The tool is generally clear, complete, and up to date, with minor areas for improvement
Fair – The tool has notable gaps or ambiguities that could impact safe and effective handoffs
Poor – The tool is unclear, incomplete, or lacks critical information needed for safe and effective handoffs
Not Applicable – A written handoff tool was not reviewed
Did you provide verbal feedback to the handoff team?
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Yes
No
Share one REINFORCING piece of feedback based on your handoff observation
Share one CORRECTIVE piece of feedback based on your handoff observation
Observer Name
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First
Last
