Handout #3
FWMEP Family Medicine RESIDENCY
Patient Hand-Off Evaluation Form
Resident(s):________________________________
Date:___________________
□ The Hand-Off was done in a quiet and controlled environment in order to limit distractions
□ The Hand-Off was done face to face and interactive.
□ The Resident used the Approved Patient List Hand-Off Template
□ All of the required elements were completed for each patient during the Hand-Off:
□ Significant Exam Findings
□ Lab/X-ray Data
□ Clinic Changes/Condition
□ Family Contact Info
□ Any Change in Attending Physician
□ The Resident used the DRAW Mnemonic/Format to conduct the Patient Hand-Off
□ The transmitting resident articulated the Recent Changes and Anticipated Changes
(including pending diagnostics and consultations) succinctly, on-target, and with
appropriate thoroughness for peer level.
□ N/A (not the transmitting resident)
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Handout #3
□ The receiving resident was able to project the most likely anticipated progression
and clinical course of patient for peer level.
□ N/A (not the receiving resident)
□ The receiving resident was able to articulate the most likely alternative clinical
scenarios and “What to Watch out for” of patient for peer level.
□ N/A (not the receiving resident)
□ The receiving resident was able to articulate “What might harm” the patient for
peer level.
Overall the resident performed the Hand-Off:
□ Competence demonstrated
□ Nearing Competence
□ Beginner/learner
□ Improvement needed for peer level
____________________________________
Signature of Supervising Senior Resident
____________________________________
Signature of Supervising Faculty
When form completed turn it in to Mr. Eric Whicker
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