Nursing Handoff Checklist & Worksheet

Required Knowledge About Each Patient

Patient Problems/Systems Assessment
Neurological
[Place Patient Label Here]  Level of consciousness  Neurological deficits  Pain score/meds

Attending Physician:
Consulting Physician(s): Cardiovascular
History  Lab results  PRN meds  Telemetry  Rhythm  Tubes/drains
Diagnosis:  Peripheral pulses/edema  IV access/location/drip meds
 Pacemaker settings/rate

History:

Respiratory
 Lab results  PRN meds  O2 sat/requirements  Breath sounds
 Tracheotomy/chest tubes/drains  Sputum characteristics

Allergies:

Fall risk?  No  Yes, due to:

Restraints?  No  Yes
Isolation?  No  Yes Gastrointestinal
 Lab results  PRN meds  Bowel sounds/movement/consistency
 Nutrition  Rectal tubes/output/ostomies  Oral care
Code status:

Vital Signs & Weight:

Genitourinary
01 02 03 04 05 06 07 08 09 10 11 12
Meds  Lab results  PRN meds  Urine output/color/sediment
13 14 15 16 17 18 19 20 21 22 23 24
 Voiding/catheter  Dialysis
Plan of Care
Pending procedures / tests:

Endocrine
Results of procedures / tests:  Lab results  PRN meds  Blood sugar

Clinical pathways / guidelines / protocols: Integumentary

 Decubitus ulcer stage/treatment  Erythema/rash
 Surgical incisions/dressing  Specialty bed
Education needs / IPOC:

If smoker, cessation education given:  No  Yes

Vaccines update:  No  Yes

Purpose/Desired Outcome
Anticipated discharge/transfer date: Musculoskeletal
 Weakness/paralysis  Mobility/activity level  Assistive devices
 Joint swelling/tenderness
Discharge/transfer destination:

Precautions
Concerns and priorities for my patient: Psychosocial
 Behavioral/mental health  Family dynamics/support system
 Customer service issues

“Excellent Report” Criteria:

5P Handoff  Concise  Uninterrupted  Walking Rounds