STANDARD WORK
Bed Side Handover process from
shift to shift
Operation:
Equipment; Parts; Tools;
Materials
Related Documents;
Forms
#
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•
•
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COW (computer on wheels)
Green/Red file
Ward Procedural Charge File
Takeover sheet
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WI-NUR-GEN-006 Patient Handover
WORK SEQUENCE
SW No.: SW-NUR-GEN-001
SW Rev: 1
Effective: 11/04/11
DD/MM/YY
STANDARD/SCRIPT
Time/ Duration
(Specifications, Quality, Safety)
1
PN pushes a COW and arrives at the designated bed
with team (PNs, EN/HCA)
2
PN and team taking over shift to approach patient at
bedside
1. Greet patient, introduce self and team.
Hand over using a low tone of voice that is loud
enough for your team to hear but not within earshot of
neighbouring patients (this includes anyone who is not
supposed to hear). If necessary, move out of the
cubicle.
100% compliance of the Script:”Good morning /
afternoon / evening Mdm/Mr/Ms XXX, I am Staff
Nurse NAME. This is my team. We will be taking care
of you during this shift.”
2. Assess for pain
Script: “Are you experiencing any pain now?
If yes, “On a scale of 0-10, when 0 is no pain and 10
is worst pain. Are you able to rate the current pain you
are experiencing?”
Observe for sign of distress if unable to verbalize
3. Assess for bowel movement.
Script:” Have you pass motion today?”
4. Ask patient if he/she has taken diet, or has sleep well
in accordance to shift.
5. Check invasive lines (if any). Any abnormal signs and
symptoms of phlebitis, bleeding, loose connections,
dislodgements.
Script:
ND-AM: “Did you sleep well?
AM-PM: “Did you eat your lunch?”
PM-ND: “Did you eat your dinner?”
Exclude patients who are unable to take orally e.g.
patient on NBM or NGT
Site dated. Dressing clean.
6. Verify infusion - infusion fluid, route and rate (if any).
Tally with order in EIMR
7. Check environment- any medication left on the locker, Wearable effects such as ring; bangles and chain on
patients not too tight i.e. with two finger spacing which
dentures, hearing aids or personal effects present.
do not impede circulation.
SW Template Rev.B- 20090319
This template is created by TTSH-HRD. For information, please contact Koh Huey Bing: koh_huey_bing@ttsh.com.sg at ext. 8629 or Reandy Yang: reandy_yang_yc@ttsh.com.sg, ext 1894
8. Verify and update headboard accurately.
Name- to write surname/family name with initials.
Name
Discipline
Language/dialect
Diet
Denture
Hearing Aid
Functional Status
Oral Hygiene
PU Care Bundle
9. Reinforce on fall precaution (if applicable) and to
emphasize on use of call bell for assistance.
3
Pink headboard and Pink wrist tag for patient on fall
risk.
PNs to open 4 windows simultaneously to view clinical
information together.
1. SmartSense
- Vital signs trending, Pain score, Bowel
Deranged /abnormal reading is reported.
- Drainage (where applicable)
- Weight (where applicable)
- POD (where applicable)
2. EIMR
- Open ‘View all Med’ page to view the active
medication list.
- Ensure medications are served timely.
Timing as reflected in the Inpatient Med Admin page
in EIMR.
- Valid reasons are available for omission of medicine.
Indicate
Timing
- Non-omnicell medications are available.
- Odd timing medications to be served at during shift are
noted.
Recommendation: For odd timing medications, can
use flagging board as reminder.
3. Aurora
- Type of lab / radiology investigations ordered
- Status of investigations / appointments
Deranged /abnormal result is reported.
- Results
4. EMOS
- Verified types of diet ordered.
Tally with Nursing Kardex and headboard.
SW Template Rev.B- 20090319
This template is created by TTSH-HRD. For information, please contact Koh Huey Bing: koh_huey_bing@ttsh.com.sg at ext. 8629 or Reandy Yang: reandy_yang_yc@ttsh.com.sg, ext 1894
4
PNs to go through the documents in the green/red
folder together. To communicate if any issues arise.
Team to verify records and monitoring charts are
updated.
- Treatment sheet (include updates from continuation
sheet, refer to clinical pathway if applicable)
- Nursing Kardex
- Monitoring Charts (E.g. Fluid regime, Diabetic, CLC,
Intake/ Output, Chest Tube, Restrainer, Suctioning,
Neurovascular, Peak Flow, Suicide Caution, Fall
prevention, oral hygiene, PU Bundle Form
Fits chart, Postural BP).
5
AN/HCA clarify with PN if any queries.
AN / HCA check in blue folder:
- Ward procedural charge form
Ensure all procedures done and consumable are
charge accordingly
PN hands over patient information based on the PCR,
Clinical pathway, PFE, discharge planning, mWheFRA
score, and communication chart, where applicable.
Use structured takeover sheet e.g. Trendcare patient
report for note taking.
- Not to update on the spot.
- Any new changes updated by PNs after handing over
to be communicated before going off shift.
6
PN taking over shift to clarify any doubts
Move on to patient at next bed when ready
Repeat step 2-6 till PN and team reach the last patient
assigned
Created by:
Lum Yuat Soon / Tan Tzuu Ling
Department:
Nursing Service
Ext: 3008
7
Approved by:
Validated with:
Kwek Puay Ee Director, Nursing
Nursing Standards Committee
SW Template Rev.B- 20090319
This template is created by TTSH-HRD. For information, please contact Koh Huey Bing: koh_huey_bing@ttsh.com.sg at ext. 8629 or Reandy Yang: reandy_yang_yc@ttsh.com.sg, ext 1894