Clinical Handover - | Health



Canberra Hospital and Health ServicesClinical ProcedureClinical HandoverContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc505933966 \h 1Purpose PAGEREF _Toc505933967 \h 2Scope PAGEREF _Toc505933968 \h 2Section 1 – All Clinical Handovers PAGEREF _Toc505933969 \h 2Section 2 – Verbal Handovers using ISBAR PAGEREF _Toc505933970 \h 4Section 3 – Written Handover and Documentation PAGEREF _Toc505933971 \h 5Implementation PAGEREF _Toc505933972 \h 6Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc505933973 \h 6References PAGEREF _Toc505933974 \h 7Definition of Terms PAGEREF _Toc505933975 \h 7Search Terms PAGEREF _Toc505933976 \h 8Attachments PAGEREF _Toc505933977 \h 8Attachment 1: Situations for Clinical Handover PAGEREF _Toc505933978 \h 9Attachment 2: Examples of CHHS handover formats to General Practitioners and Community Services PAGEREF _Toc505933979 \h 10Attachment 3: ISBAR for Verbal Handover PAGEREF _Toc505933980 \h 11Attachment 4: Example of ward handover sheet in ISBAR format PAGEREF _Toc505933981 \h 12Attachment 5: ISBAR for Telephone Handover PAGEREF _Toc505933982 \h 13Attachment 6: ISBAR example for receiving or providing clinical investigation results via the phone PAGEREF _Toc505933983 \h 14Attachment 7: Example components of written documentation using ISOAP from the Community Care Program PAGEREF _Toc505933984 \h 15PurposeThe purpose of this procedure is to have a standardised clinical handover process in place to facilitate timely, relevant and structured transfer of information regarding a consumer’s care between health care clinicians to enhance the continuity of care and optimise consumer safety.This will facilitate:Consistency in clinical handover with essential information;Consumer safety; andMaintenance of and compliance with current best practice standards. Back to Table of ContentsScopeThis procedure applies to all ACT Health staff and students involved in and responsible for consumer care and the transfer of accountability for a consumer’s care from one person to another, this includes both direct and indirect care. Back to Table of ContentsSection 1 – All Clinical HandoversClinical Handover refers to the transfer of information, professional responsibility and accountability for some or all aspects of care for a consumer, or group of consumers, to another person or professional group on a temporary or permanent basis. See attachment 1 for a guideline of situations for clinical handover.At each point of handover during the consumer journey:Use the consumer record to cross-check information, using the three unique identifiers as per CHHS Patient Identification and Procedure Matching Policy and municate all important findings or changes of condition/care, including reference to medication, infection status and relevant precautions, all clinical risks including falls and pressure injury and risk of deterioration and estimated date of discharge. Ensure clinician receiving handover understands and accepts the handover.Ensure, where relevant a multidisciplinary approach is taken.Ensure, where possible, that consumers and carers are included in handover discussions.Ensure accountability and responsibility for consumer care is assigned and understood.Document in the clinical record when handover of care has occurred. All clinical areas/divisions Must have in place mechanisms to detail their local processes for handover that adhere to this procedure (such Clinical Handover in MHJHADS Procedure). These include: Mechanisms to include consumers and carers in clinical handover processes related to their care, for example, incorporate bedside handover.Handover tools and procedures are relevant to the type of handover occurring.Documented processes for handover are in place and include, but are not limited to:Ensuring all relevant staff are present, organised, educated and prepared for handover.Ensuring process are in place for transfer of responsibility (for example, to another health care team or shift to shift handover).Instances during the consumer journey where handover occurs (for example, ward clinical staff to Medical Imaging clinical staff).Established internal processes and resources to utilise the ISBAR (Introduction, Situation, Background, Assessment, Recommendation/Read back) or ISOAP (Identification, Subjective information, Objective information, Analysis/ Action/ Advice, Plan) tool (see section 2 and 3), for example: Referral forms which incorporate the ISOAP tool as headings.Tools to support telephone handovers.Ward lists which incorporate ISBAR (See Attachment 1).Prompt sheets for staff use during verbal handover.Electronic templates for written handover or discharge which incorporate ISOAP.Documented organisational procedures for escalation of critical incidents involving clinical handover.Clinical handovers can vary depending on consumer circumstance; points of handover include but are not limited to:during a shift changewhen consumers are transferred within a health facility and/or between health facilitiesduring admission, referral or dischargeclinician to clinicianbetween disciplines between teams.Methods of handover can include:face-to-facetelephone or telehealthclinical documentationwritten orders including discharge summariesoutpatient letters (e.g. by Medical Officers, Allied Health, Nurse Practitioners, etc.)electronic handover tools including e-Referrals. The following examples, including CHHS handover formats to General Practitioners and community based services, have been included as attachments: Attachment 2: Examples of CHHS handover formats to General Practitioners and Community ServicesAttachment 3: ISBAR for Verbal HandoverAttachment 4: Example of ward handover sheet in ISBAR formatAttachment 5: ISBAR for Telephone HandoverAttachment 6: ISBAR example for receiving or providing clinical investigation results via the phoneAttachment 7: Example components of written documentation using ISOAP from the Community Care ProgramClinical Handover in the inpatient hospital setting Clinical Handovers in hospital settings will occur at the consumer’s bedside where possible. Opportunity should be provided at each handover for consumers/carers to be involved. The involvement of carers or visitors in handover can only occur following consent from the consumer. Whilst it is preferable that handover occur at the consumer’s bedside, handover may take place elsewhere, such as:in a common staff only areaat a hospitalAlert: Staff must be aware of maintaining consumer privacy in common areas and multi bed rooms and should seek agreement from the consumer to proceed with the handover of their information. Handover in the ambulatory or community setting All clinical handovers in the community setting either written, verbal or via e-referral are required to comply with the Patient Identification and Procedure Matching Policy and Procedure and the principles of handover using ISBAR or ISOAP.Back to Table of Contents Section 2 – Verbal Handovers using ISBARVerbal HandoversAll verbal handovers will use the ISBAR (introduction, situation, background, assessment, recommendation/read back) method of handover. This ensures that handover includes the following information at a minimum in the handover process. Note: ISBAR refers to the minimum amount of information that must be contained in every clinical handover. Clinical areas may choose to utilise ISOBAR instead where the ‘O’ stands for Observation.This data set must include the following (see Attachment 3 and 4):Introduction:Use three unique identifiers (Name, DOB, URN or address) to identify the consumer, introduce yourself and the clinician taking over the consumer’s careSituation:State the immediate clinical situation of the consumer and list the most important and recent observations including interpretation of observationsBackground:Provide relevant background/history to the consumer's clinical situation; i.e. reason for admission and other health and risk factors including allergies and infection statusAssessment:Identify assessments, including risks and actions that need to occur; i.e. anticipated consults, test results, risk of falls, risk of deterioration, etc. Recommendations/ Read back:Identify timeframes and requirements for handover of care. Read back is an opportunity for staff/consumer/carers to ask questions or comment. Ask receiver to repeat key information to ensure a shared understanding. Phone Handover of ResultsWhen staff are receiving results over the phone ISBAR must be used (see attachment 6). Medical Imaging For procedures around handover of results from Medical Imaging please refer to the Communication of urgent and unexpected findings – Medical Imaging Procedure.PathologyAll handovers to or from pathology are required to comply with the Pathology Requests and Specimens Procedure and the Patient Identification – Pathology Specimen Labelling and the principles of handover.Back to Table of Contents Section 3 – Written Handover and Documentation Documentation of Clinical InterventionsFor written handover ISOAP (Identification of those present including staff/consumer/others, subjective information, objective information, analysis/ action/ advice and plan) is recommended and should follow these principles: All clinical interventions must be documented and include any relevant information that is likely to impact on the clinical care of the consumer.Clinical documentation should be completed at the time of intervention. If this is not possible, documentation must be completed before the end of the shift in which the intervention occurred.All clinical documentation should comply with the Clinical Record Management Procedure.Documentation is to be organised according to the (I)SOAP tool headings (see attachment 6): I: Intervention/IntroductionIdentify yourself and give your reason for the clinical handover or interventions planned. Identify consumer using unique identifiers and others present such as carer, advocate or interpreter. S : subjective informationPresentation of the consumer’s viewpoint – their story, how they may feelO: objective information Objective observations of the consumer – factual, unbiased and measurable A: analysis/action/advice Analysis and interpretation of subjective and objective information followed by action implemented and any related advice or education providedP: plan Plan of care to incorporate any required changes to interventions and time frames – includes changes to care plansDischarge SummariesAll discharge summaries should be completed within 48 hours of discharge as per the Discharge Summary Completion Procedure. When completing the discharge summary ensure that the consumer’s General Practitioner (GP) (or facility the consumer is being discharged to) is known, so that they may receive a copy. The consumer should be provided with a copy of the discharge summary at the time of discharge.Outpatient Letters All outpatient letters should incorporate the principles of written handover using ISOAP and be compliant with the Transcription Framework.Back to Table of ContentsImplementation Notification regarding this procedure will occur via the ACT Health Intranet HUB and Deputy-Director General bulletin and ACT Health Executive meetings.Clinical Handover processes will be included during orientation of all new clinical staff to ACT Health.Techniques and tools for Clinical Handover are included in the following training and updates for clinical staff, including:COMPASS training Clinical Handover eLearning on Capabiliti Clinical Records Documentation Requirements eLearning on CapabilitiBack to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationLegislationHealth Records (Privacy and Access) Act 1997Mental Health Act 2015Human Rights Act 2004Public Sector Management Act 1994Health Practitioner Regulation National Law (ACT) Act 2010Health Practitioner Regulation National Law Act 2009Health Practitioner Regulation National Law RegulationWork Health and Safety Act 2011Carers Recognition Act 2010PoliciesPatient Identification and Procedure Matching PolicyConsumer Feedback Management in the Health Directorate PolicyACT Health Work Health and Safety Policy ACT Health Work Health and Safety Management System ACT Health Incident Management Policy ProceduresConsumer Feedback Management in the Health Directorate ProcedureClinical Record Documentation ProcedureCommunication of urgent and unexpected findings – Medical Imaging ProcedureDischarge Summary Completion ProcedurePatient Identification and Procedure Matching ProcedureClinical Handover in MHJHADS ProcedurePathology Requests and Specimens ProcedurePatient Identification – Pathology Specimen LabellingStandards and Guidelines Australian Commission on Safety and Quality in Healthcare National Safety and Quality Health Service Standards, 2017.Consumer Feedback Standards: Listening and LearningAustralian Guidelines for the Prevention and Control of Infection in Healthcare (2010)Australian Charter of Healthcare RightsBack to Table of ContentsReferencesAustralian Medical Association (AMA). (2006). Safe Handover Safe Patients – Guidance on Clinical Handover for Clinicians and Managers. Retrieved from: Australian Commission on Safety and Quality in Health Care (ACSQHC). (2010). the OSSIE Guide to Clinical Handover Improvement. Sydney, ACSQHC. Retrieved from: National Safety and Quality in Health Service Standards, Australian Commission on Safety and Quality in Health Care. to Table of ContentsDefinition of Terms ISBAR - introduction/situation, background, assessment, recommendation/read back)IS(O)BAR - introduction/situation, observation, background, assessment, recommendation/read back)ISOAP - Identification of reporter/consumer/others present, subjective information, objective information, analysis/ action/ advice and planBack to Table of ContentsSearch Terms Handover, Transfer of Care, ISBAR, IS(O)BAR, ISOAP, e-referral, referralBack to Table of ContentsAttachmentsAttachment 1:Situations for Clinical HandoverAttachment 2:Examples of CHHS handover formats to General Practitioners and Community Services Attachment 3:ISBAR for Verbal HandoverAttachment 4:Example of ward handover sheet in ISBAR format Attachment 5:ISBAR for Telephone Handover Attachment 6:ISBAR example for receiving or providing clinical investigation results via phoneAttachment 7:Example components of written documentation using ISOAP from the Community Care ProgramDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 21/02/2018Complete ReviewJane Murkin, DDG, QGRCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS15/069Clinical HandoverAttachment 1: Situations for Clinical Handover These guidelines are provided to assist staff in developing handover processes in specific clinical areas/situations, including WHY, WHAT, WHO, WHEN and HOW solutions should a handover occur.WHYImplement standard key?principles?Provide the best consumer care by improving the transfer of clinical information, responsibility?and?accountability.WHATClinical information is?handed over?Locally defined minimum data set that meets the key principles, ensuring the most important clinical information is handed over.**WHOShould attend the handover?Key participants in the handover process are identified and available to attend the clinical handover of?their consumers.WHENShould handover occur?Escalation of deteriorating consumerConsumer transfers to another wardShift to shift change overConsumer transfers for a test or appointmentConsumer transfers to another facilityMulti-disciplinary team handoverConsumer transfers to/from the communityHOWShould handover be delivered?Face to face + checklistIn the consumers presence (bedside handover)Face to face verbal onlyChecklistIn a common staff areaTelephone handoverMobile electronic toolsDetailed transfer letterTape recordingAdapted from source: Implementation Toolkit: Standard Key Principles for Clinical Handover, NSW Department of Health 2009 14 LegendRecommended OptionsNot RecommendedShould Never OccurAttachment 2: Examples of CHHS handover formats to General Practitioners and Community Services Handover formats from CHHS to GPClinical Portal (Electronic Discharge Summary) Birth Outcomes System (BOS) Maternity consumers for uncomplicated births only Day Surgery Patient Operation ReportEmergency Department Information System (EDIS) Discharge Letter MAJICeR Electronic Discharge Summary (inpatient) and Letter to the GP (community)Chest Pain Assessment and Discharge FormOutpatient letters (e.g. by Medical Officers, Allied Health, Nurse Practitioners, etc.)Plastics or Orthopaedic Registrar Review Clinic Summary Centre for Newborn Care Discharge SummaryElective Short Stay Cardiac Procedures Admission and DischargeAttachment 3: ISBAR for Verbal Handover NB: O can be added for observations (e.g. ISOBAR)Attachment 4: Example of ward handover sheet in ISBAR format Using ISBAR for Ward Handover Sheet INTRODUCTIONSITUATION/BACKGROUNDASSESSMENT & ACTIONSRECOMMENDATIONSBed/Room No.Name/URN/ConsultantAgeDiagnosis (situation)Relevant medical history (Background)DietOBSBSLIVT/IVABSMobilityDrains/IDCPlans/Recommendations(date)Allied HealthAD/EDDAttachment 5: ISBAR for Telephone HandoverUsing ISBAR in a telephone handover from Nurse to Doctor regarding deteriorating consumer.Example of how ISBAR can be adapted for different clinical situations. Taken from Early Recognition of the Deteriorating Patient Program, ACT Health 2007.NB: O can be added for observations (e.g. ISOBAR)Attachment 6: ISBAR example for receiving or providing clinical investigation results via the phoneIntroduction:Using the three unique identifiers (Name, URN and DOB) identify the consumer the results pertain to. Identify yourself and identify the caller who is providing the results over the phone.Situation:Request the reasons for the results, as per the request form. Background:Discuss relevant background. Assessment:Identify if any results were urgent or unexpected.Recommendations/ Read back:Read back is an opportunity for staff to ask questions or comment. Ask receiver to repeat key information to ensure a shared understanding. Attachment 7: Example components of written documentation using ISOAP from the Community Care Program DOCUMENTING CLINICAL INTERVENTIONSIIntroductionSet the sceneIdentify yourself (name, designation, team, time and date)Who is present (carer, family, interpreter, student)?Where did the intervention take place (health centre, ward, home visit)?What type of intervention is it (referral, admission, review or routine report)? SSubjective information The consumer viewpointWhat is the consumer’s story?How do they feel? What symptoms are described by the consumer (severity, location, duration & frequency)?Does the consumer report past medical/social history which is relevant?Is relevant information provided by other people present?Use quotation marks or client states.OObjective information Objective observations of the consumer – factual, unbiased and measurableWhat do you see?What are the results of your examinations? AAnalysis/action/adviceAnalysis and interpretation of subjective and objective information What is your clinical reasoning? Action implemented What did you do? Advice or education provided What did you tell the consumer? PPlan Plan of care - What happens next? What interventions have you planned?What time frames have you set for review or recovery?Who have you corresponded with or referred to? ................
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