HAND OFF COMMUNICATION WORK SHEET



HAND OFF COMMUNICATION WORK SHEET

Check off , and document what was communicated

Name MD:

Admitting MD:

Age

Diagnosis

Allergies

Code Status: DNR DNI not addressed

Family/Significant Other location:

Pertinent History: Not Addressed

Patient responsible for own consent Yes No

If no, legal guard or POA:

Treatments / Assessment

Mentation: Alert Oriented Confused Obtunded

Other

Vital Signs: T P R B/P SaO2

Oxygen No Yes

Critical Labs

Pain Score

Meds given

Med reconciliation done? Yes No

Tubing / Line Reconciliation

NSL Fluid/rate Med running

Foley NG Other:

Special Concerns

None

NPO

Impairments: Hearing _____Visual_____ Cognitive _____ Mobility _____Other:

Fall risk

Infectious Disease precaution level

Run Risk

Suicide Precautions

Other

Date: Time:

Report given by:

Report taken by:

For Pre-Op Patients ONLY: Pre-op checklist complete: Yes No

RETAIN IN PATIENT CHART UNTIL DISCHARGE

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4/25/07

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