RN TO RN HANDOFF TOOL - NurseMind
SITUATION
Identifying Information 1. Name, gender, age,
room # 2. MD, Diagnosis 3. Code status, Allergies
Name: M / F Age: MD:
Room:
Diagnosis:
Code Status:
Allergies: Name: M / F Age: MD:
Room:
Diagnosis:
Code Status:
Allergies: Name: M / F Age: MD:
Room:
Diagnosis:
Code Status:
Allergies:
Name: M / F Age: MD:
Room:
Diagnosis:
Code Status:
Allergies: Name: M / F Age: MD:
Room:
Diagnosis:
Code Status:
Allergies:
BACKGROUND
What patient information relates to what is going on now? 4. Relevant past history/comorbidities 5. History of hospital course, tests, procedures 6. Medications related to problem/concern 7. Standards or Precautions: Fall, Seizure, HOH, Lang Barrier, Isolation, Sitter, Restraints, Aspiration, Skin/Wnd 8. Altered findings: Neuro, CV, Resp, GI/GU, Skin/Wnd, Lines, Tubes, Fluids, Blood Transf, VS, Pain, Labs, XRay
RN TO RN HANDOFF TOOL
ASSESSMENT
What is the patient's overall condition? 9. What are your concerns? 10. What have you done about them? 11. Have the interventions been effective? 12. Priority Nursing Diagnosis 13. Is the patient STABLE or UNSTABLE ? 14. Expected Discharge Date 15. Barriers to Discharge: Pain, Mobility, Skin, Inf, Oth
RECOMMENDATIONS
What is the recommendation for patient care planning? 16. Goals for patient stability Pathophysiology, Psych, Behavioral, Cognitive, Social, Spiritual 17. Plan for care include surgery or procedural preparation 18. Care Coordination PT, OT, Speech, MSW, Respiratory, Neuropsych, Respiratory, Case Management 19. Teaching/Discharge Plan 20. Any other questions or concerns
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