Psychiatric Policy 7.7
Written: 1/07
Psychiatric Policy 7.7
Reviewed: 1/10
LSU Health Shreveport
Revised: 1/13
Psychiatric Unit
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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
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Psychiatric Policy
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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.
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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
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