Psychiatric Policy 7.7 Written: 1/07 Psychiatric Policy 7.7 Reviewed: 1/10 LSU Health Shreveport Revised: 1/13 Psychiatric Unit ________________________________________________________________________ Patient Hand off Communication Policy Purpose: To define patient care communications from one care giver to another To provide complete and accurate information to assure safe and effective continuity of care Policy 1. New Patient Report – information to be obtained when receiving patient report on a new patient being admitted to the Psychiatric Unit a. Patient Name b. Diagnosis/Chief Complaint c. Legal Status with expiration date/time of papers d. Orientation of Patient e. Vital Signs f. Medications g. Labs h. Pain information i. Pending Exams/Medical Tests 2. Change of Shift Report a. On Coming Staff - all nurse and aide staff are required to attend report for the wing they are assigned - all staff must use wing specific report sheet that lists patients name, age, gender, race, room number and assigned physician team - staff shall be given an opportunity to ask questions - the wing team leader will submit a copy of their wing’s report to the charge nurse - the wing team leader will supply staff that miss report or lose their report sheet a copy of the wing’s report - document in Electronic Health Record (EHR) who gives on coming nurse report on patients b. Off Going Staff - licensed nurse staff shall give verbal shift report - “Nurse Report” form format will be used - nurse will use Kardex to give report 1 Psychiatric Policy - Nurse will answer oncoming staff questions document in EHR who they give report to on next shift c. In order to ensure clear and accurate communication during patient handoffs, acceptance of new patient admits will be suspended 15 minutes prior to shift change time and 15 minutes post shift change time. d. “Nurse Report” form will include the following information: 1. Patient Name/Age/Race/Gender/Diagnosis 2. Legal Status 3. Diet & Appetite 4. Grooming & Dress 5. Affect/Speech/Mood 6. Thought Process 7. Thinking Impairment 8. Interaction with Peers 9. Precautions / Privileges 10. Patient Care Techniques 11. Medical Issues 12. Medicine Needs 3. Change of Caregiver during shift a. Primary caregiver temporarily leaves the unit - The team leader is to be advised when any caregivers leaves the wing they are assigned. - The team leader will assign staff as needed for patient care. b. Sending a patient to other sites for care - Documentation must be made in the electronic health record. - During computer downtime the Inpatient Transport Summary (SN 7280) must be completed by the patient’s Nurse and sent with the patient. This form is used when nurse is not escorting the patient to another department for test or procedures. c. Sending a patient to surgery - Documentation must be made in the electronic health record. - During computer downtime the Pre-Op Checklist (SN 1185) will be completed by the patient’s nurse and sent with the patient to surgery. - Psychiatric patients that their primary diagnosis converts to medical issues will be discharged to Medicine/Surgery. 4. Medical Patients Patients that have medical problems and are being discharged to a medical unit or intensive care unit require the nurse to personally accompany the patient and provide hand-off communication to the receiving nurse. 2 Psychiatric Policy 5. Treatment Team Report a. Nurse Staff will have available “Nurse Report” form information for interdisciplinary team meeting 6. Nurse to Physician Communication a. If possible nurse to physician communications will be verbal b. When verbal communication is not practical the Charge Nurse may send an electronic message to the Attending Physician 7. Discharge Patient Report a. Documentation in the electronic health record will be completed by the RN/LPN on all patients discharged from the hospital. During computer downtime the discharge section on The Patient History and Discharge Record (SN 6677) will be utilized. b. The After Visit Summary (AVS) Report will be used when discharging a patient to another unit or facility. During computer downtime the The Transfer-Discharge Summary (SN 1116) will be utilized. c. The After Visit Summary (AVS) Report with patient discharge instructions will be given to all patients discharging. During computer downtime the Discharge Instructions (SN 7073/7074) is completed and given to patients discharging home. d. The After Visit Summary (AVS) Report with medication administration instructions will be given to all patients discharging. During computer downtime the Medication Reconciliation (SN 7266) will be utilized and given to the patient. e. The Memorandum of Inter-Hospital Transfer (SN 1303/1330) will be completed by the physician when transferring a patient to another acute care facility. f. When discharging to another unit or facility a verbal report will also be called to the accepting unit or facility 8. Verification of Information a. Repeat back and read back techniques will be used to verify accuracy of vital signs and all critical information. 9. Patient Confidentiality a. After use, patient hand off communication forms, that contain patient information, shall be shredded. Reference: Hospital Policy 5.43 3