Strategies and Tools to Improve

Patient Name Inpatient Transfer Sheet “I PASS the BATON”

Introduction of the oncoming and off-going provider. I Introduction Make sure that there are opportunities for staff to ask questions, clarify information and confirm.

Make sure that the correct patient is identified during the handoff process. Check patient’s name (ask the patient to tell you their name) P Patient Was Family Informed of transfer?  YES  NO Name Band Checked:  YES  NO Patient transferring from:  Emergency Dept  Outside Hospital  Other______

Chief complaint:______A Assessment Diagnosis:______Vital Signs: T______P______R______BP______Rhythm ______O2 Sat ______WT ______

 P-DNR in place (see attached) Level of Consciousness:  Fully Awake  Sleepy but Arouses Easily  Unresponsive Nutrition/fluids/IV:  Tolerating PO Fluids  Taking sips, ice chips only  Nausea & Vomiting  Venous Access: Date Inserted______ IV infusing______Elimination:  Voiding QS  Has not Voided  Catheterized: Date/Time: ______ Indwelling Foley Patent  Bowel Pattern (specify);______ Last BM - Date:______S Situation I: ______O: ______N/A  Comfort:  Free of Pain  Minimal Pain  Moderate-to-Severe Pain Pain Med Last Given: ______Wound status: Location ______ No Bleeding  Amount of Bleeding ______ Date/Time Last Dressing Change:______ Splint/Sling/Brace (type) ______Activity:  Up Ad Lib  Up With Assistance  On Bed rest Oxygen: ______

Critical Lab Values/reports or studies: ______Safety Allergies: ______S Concerns Alerts:  Fall Risk  Isolation (type) ______ Restraints (type)______Condition at Transfer:  Stable  Guarded  Critical THE

Pertinent co-morbid conditions / previous episodes ______B Background Primary Language: ______Current Medications  Medication List / MAR Attached ______Pertinent Family History: ______

What actions were taken or are required (provide brief rationale) Orders/tests/procedures to be done and timing Actions ______A (Recommendations) ______

Level of urgency and explicit timing, prioritization of actions Any stat meds, tests, procedure ordered? ______Given?  ______Antibiotic  yes timing of next dose______(PostOp/ ED Pts) T Timing (Recommendations) ______

Report Given to:______Who is responsible (nurse/doctor/team) for patient? ______O Ownership Physician ______Family Contact ______DPOA/Guardian ______

What will happen next? Anticipated changes? What is the PLAN? Contingency plans? ______N Next ______Expected Surgery  Yes  No Expected Discharge/Transfer to other facility______

Attachments:  H & P/ Discharge Summary  P-DNR form  Current Med List  Pertinent Labs, X-Ray  Insurance Comments: ______Signature of Transferring Nurse and phone # Date / Time