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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