nursing patient handover template

Clinical Shift Change Communication Protocol

Document Control

• Document ID: SOP-NURS-001
• Version: 1.0.0
• Effective Date: [__________]
• Review Cycle: Annual

1. Purpose & Scope

This procedure establishes a standardized, high-reliability framework for the transfer of clinical information between nursing staff. The scope encompasses all bedside shift reports, inter-departmental transfers, and escalation handovers occurring within [Facility Name].

2. Prerequisites

• Access to [Electronic Health Record System Name]
• Current patient chart and [Device/Hardware Name]
• Standardized clinical handover form/template
• Secure, private environment designated for handover

3. Roles & Responsibilities (RACI)

4. Step-by-Step Procedure

Phase 1: Preparation (T-minus 10 minutes)

• Verify patient data in [Electronic Health Record System Name] is up-to-date.
• Ensure all critical lab results and diagnostic reports are reviewed.
• Organize patient status summary: [Name], [Age], [Diagnosis], [Code Status].

Phase 2: The SBAR Exchange

• Situation: State patient name, room number, and primary reason for admission.
• Background: Summarize medical history, allergies, and pertinent recent events.
• Assessment: Describe current vitals, physical assessment findings, and pain status.
• Recommendation: Outline the plan of care, pending orders, and specific tasks for the upcoming shift.

Phase 3: Bedside Verification

• Conduct a visual safety check of IV lines, wound dressings, and medical equipment.
• Confirm patient identification using [Facility Identification Protocol].
• Invite the patient/family to participate in the handover discussion.

Phase 4: Closure & Handover Completion

• Incoming nurse repeats back critical tasks and pending orders.
• Document the successful completion of the handover in [System Name].
• Confirm transfer of accountability for all patient care duties.

5. Quality Assurance, Pro-Tips, and Pitfalls

• QA Metric: 100% compliance with SBAR structure and bedside verification.
• Pro-Tip: Use the "Read-Back" method for all medication adjustments or critical orders to ensure zero communication drift.
• Common Pitfall: Avoiding the bedside. Always conduct the handover at the patient's side unless clinically contraindicated, as this reduces errors by 30%.

6. FAQs

Q: What should I do if the incoming nurse is delayed? A: If the incoming nurse is delayed by more than [__________] minutes, notify the Charge Nurse to ensure patient safety is maintained and handover is prioritized.

Q: How do I handle a handover for a patient with complex psychosocial needs? A: Prioritize the "Background" section of the SBAR to include specific behavioral triggers, support systems, and communication barriers identified during the previous shift.