Transcript Patient Handoffs

Safe & Effective Handoffs
Subha Airan-Javia
Penn Hospitalist Medicine
PT INFO
HPI
PROB LIST
MEDS
To Do
X Cover
Smith,
John Bob
F14
1465A
MR:
34520XXX
56 yo male with
shortness of
breath for one
week
**Asp Pna –
on cefepime,
still
borderline
**ARF on
CKD: Cr 0.8
 2.5, likely
pre-renal
Cefepime
1gm IV q12
Colace
100mg po
bid
Metoprolol
100mg bid
---D/C
Info--PMD Dr.
Jones
4442244
[] f/u 7pm Na –
increase IVF if
Na <130
[] check renal note
It happened at a hospital you know…


9am rounds: 70 yo woman with DVT & h/o GI bleed
 On heparin with 48 hours of very elevated ptts (>150)
 Altered mental status & low BP  CBC ordered
1pm postcall signout: “f/u CBC”



No mention of elevated PTTs or concern for GI Bleed as
potential cause of altered mental status and low BP
3pm: Hgb = 4.0
 Wasn’t believed, another hgb was sent, no transfusion
5pm: Patient had melena, hypotension, transferred to the ICU.
 Repeat CBC confirmed Hgb of 4.
 Patient quickly coded and expired in ICU
Think About it…


Did a poor handoff contribute to this
patient outcome?
Did this patients get the care that she
expected from our hospital? How about
the care that you and I expected?
Fear of making a mistake and
harming a patient





Natural fear
You will make errors; we all do
Did parts of the hospital system make the
error easy to happen?
If so, someone else needs to know (chief
resident, program meeting, incident
reporting system)
Take care of yourself and each other
Goals for Today

Get you ready to perform safe handoffs!

Review the importance of handoffs

Teach the components of a good electronic
and verbal handoff

Practice handoffs in a simulated environment
Facts




Discontinuity in the hospital is inevitable
Discontinuity is increasing in teaching hospitals
due to duty hour regulations
Lack of communication is the most common root
cause of medical errors nationally
Communication breakdowns during handoffs can
have deleterious effects on our patients
More Facts…

Improving Handoffs is a National
Patient Safety Goal (NPSG 2E)

Implement a standardized approach to
“handoff” communications including an
opportunity to ask and respond to
questions
Being Covered by a cross-cover resident is a powerful
risk factor for preventable adverse events.
Petersen, L. A. et. al. Ann Intern Med 1994;121:866-872
Bringing it closer to home…
Day 1
6 Residents,
7 Handoffs in
5 days
ED Resident
Nightfloat JAR
Intern A - Shortcall
Day 2
On Call Intern #1
Intern A
Day 3
On Call Intern #2
Day 4
Intern A (now on Call)
Day 5
Dayfloat
Even more handoffs in the ICUs…
Day 1
ED Resident
Primary On-Call team
Dayfloat
Day 2
Nightfloat
Day 3
Primary Team
Nightfloat
4-5 Residents, 5 Handoffs in 48 hours
A handoff example….
Location: Founders 14 nurses station
Time of Day: 12:30pm post-call
People: Two July interns who don’t really
know each other yet.
What did you notice?
What did you notice?

Noisy environment

Multiple interruptions

Delivery is not standardized

No time for questions, reiteration of plan
Safe Handoff Practices
Verbal Handoff Tips

Location: as quiet as possible (away from the
nursing station, not in the ED)






Minimize interruptions
Start patient over if unavoidable
If you are worried about the patient…say it first!
Give on-call intern an opportunity to ask
questions and repeat back important facts
Review every patient
Follow the same format/order for all patients
Verbal Handoff Format

PROBLEM BASED




Sick/Not Sick
Code status (if not full code)
1-3 sentences history
PROBLEM LIST



Active issues for each
Relevant Data and Meds
Crosscover list

If/then statements, anticipatory guidance
Electronic Handoff: Purpose

Reference for primary team

Reference for covering provider
Repository of information
Discharge summary
A Novel
Electronic handoff plan


Problem list  owned by Interns
Rest of handoff  primarily resident
responsibility July – Jan


Interns should participate, edit what they
can handle
Increase your share of handoff
involvement
Handoff Progress Note

Problem List


50 Thousand foot view of problems with
short assessment & overall plan
Important medications & radiology
associated with problems


Antimicrobials, anticoagulation,
immunosuppressants, Narcotics
Concise, bulleted
Problem list
≠
Assessment and plan
Electronic Handoff Tips




Standardize: Keep info in designated location
Exclude/Remove irrelevant information
Clean-up and update handoff regularly
Avoid non-standard abbreviations



MS: multiple sclerosis, mental status, or morphine
sulfate?
HL: Hyperlipidemia or Hodgkin’s Lymphoma?
Summarize findings. Do not cut and paste
results
Electronic Handoff Tips

Problem list should be complete, but
concise



Should not be your entire progress note
word for word
This is the basis of your verbal handoff
Should be updated & reprioritized as new
problems arise and old ones change
SIGNOUT
DISCHARGE
SUMMARY
And don’t forget…

The sign-out is a TEAM document


Read by ALL disciplines in the hospital
Unprofessional language and statements
should never be written
Keys to a Good Handoff
The Nitty Gritty
Approach to verbal handoff
Sick not sick
History, Hospital Course
Objective data
Upcoming plan, dispo
To do
Approach to verbal handoff
[H O U]
S
T
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John
Bob
F14 1465A
MR:
34520984
Age, Gender, CC (on DOA): short
of breath
CC (after dx):
aspiration pna
Race, pertinent PMH, presentation
to ED, HPI.
-relevant ROS
-relevant ED issues (vitals, meds
given)
-relevant things done o/n
-important events during
hospitalizaton
11/20 – desat last night, improved
after diuresis
**Asp Pna – on cefepime,
still borderline
**ARF on CKD: Cr 0.8 
2.5, likely 2/2 dehydration.
Getting volume
**CAD – EF 10%, on
coumadin for low EF
**DM – on insulin
**HTN
**Diarrhea – possibly
CDIff, cx pending
-Prostate ca – resected,
cured
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po
bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd,
NS @ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones
444-2244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if
Na <130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L
(11/4)
Cx: >101.4
Precautions:
MRSA
Contact:
Wife Mary 215777-7777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
---PMH---hyperlipidemia
-PTSD
-chronic anemia
Approach to verbal handoff
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John
Bob
F14 1465A
MR:
34520984
Age, Gender, CC (on DOA): short
of breath
CC (after dx):
aspiration pna
Race, pertinent PMH, presentation
to ED, HPI.
-relevant ROS
-relevant ED issues (vitals, meds
given)
-relevant things done o/n
-important events during
hospitalizaton
11/20 – desat last night, improved
after diuresis
**Asp Pna – on cefepime,
still borderline
**ARF on CKD: Cr 0.8 
2.5, likely 2/2 dehydration.
Getting volume
**CAD – EF 10%, on
coumadin for low EF
**DM – on insulin
**HTN
**Diarrhea – possibly
CDIff, cx pending
-Prostate ca – resected,
cured
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po
bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd,
NS @ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones
444-2244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if
Na <130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L
(11/4)
Cx: >101.4
Precautions:
MRSA
Contact:
Wife Mary 215777-7777
S = SICK/NOT SICK
30 seconds
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
-Name
-Code Status
-Culture/Family etc
---PMH---hyperlipidemia
-PTSD
-chronic anemia
Approach to verbal handoff
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John
Bob
F14 1465A
MR:
34520984
Age, Gender, CC (on DOA): short
of breath
CC (after dx):
aspiration pna
Race, pertinent PMH, presentation
to ED, HPI.
-relevant ROS
-relevant ED issues (vitals, meds
given)
-relevant things done o/n
-important events during
hospitalizaton
11/20 – desat last night, improved
after diuresis
**Asp Pna – on cefepime,
still borderline
**ARF on CKD: Cr 0.8 
2.5, likely 2/2 dehydration.
Getting volume
**CAD – EF 10%, on
coumadin for low EF
**DM – on insulin
**HTN
**Diarrhea – possibly
CDIff, cx pending
-Prostate ca – resected,
cured
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po
bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd,
NS @ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones
444-2244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if
Na <130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L
(11/4)
Cx: >101.4
Precautions:
MRSA
Contact:
Wife Mary 215777-7777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
H = History
---PMH---hyperlipidemia
-PTSD
-chronic anemia
1-2 sentences (1 minute)
What brought the patient to the hospital
Similar to your ASSESSMENT statement on
your A/P
Approach to verbal handoff
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John
Bob
F14 1465A
MR:
34520984
Age, Gender, CC (on DOA): short
of breath
CC (after dx):
aspiration pna
Race, pertinent PMH, presentation
to ED, HPI.
-relevant ROS
-relevant ED issues (vitals, meds
given)
-relevant things done o/n
-important events during
hospitalizaton
11/20 – desat last night, improved
after diuresis
**Asp Pna – on cefepime,
still borderline
**ARF on CKD: Cr 0.8 
2.5, likely 2/2 dehydration.
Getting volume
**CAD – EF 10%, on
coumadin for low EF
**DM – on insulin
**HTN
**Diarrhea – possibly
CDIff, cx pending
-Prostate ca – resected,
cured
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po
bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd,
NS @ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones
444-2244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if
Na <130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L
(11/4)
Cx: >101.4
Precautions:
MRSA
Contact:
Wife Mary 215777-7777
---PMH---hyperlipidemia
-PTSD
-chronic anemia
“H O U”
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
Active Problems, Hospital course,
Objective data & Plan for each
MAIN AREA OF FOCUS
Approach to verbal handoff
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John
Bob
F14 1465A
MR:
34520984
Age, Gender, CC (on DOA): short
of breath
CC (after dx):
aspiration pna
Race, pertinent PMH, presentation
to ED, HPI.
-relevant ROS
-relevant ED issues (vitals, meds
given)
-relevant things done o/n
-important events during
hospitalizaton
11/20 – desat last night, improved
after diuresis
**Asp Pna – on cefepime,
still borderline
**ARF on CKD: Cr 0.8 
2.5, likely 2/2 dehydration.
Getting volume
**CAD – EF 10%, on
coumadin for low EF
**DM – on insulin
**HTN
**Diarrhea – possibly
CDIff, cx pending
-Prostate ca – resected,
cured
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po
bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd,
NS @ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones
444-2244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if
Na <130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L
(11/4)
Cx: >101.4
Precautions:
MRSA
Contact:
Wife Mary 215777-7777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
T = To Do
---PMH---hyperlipidemia
-PTSD
-chronic anemia
SECOND AREA OF FOCUS
-Go through each cross cover to do item,
what needs to be done, rationale & action
plan
-If/Then statements or other guidance
Patient Information
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John Bob
F14 1465A
MR: 34520984
Age, Gender, CC (on DOA): short of breath
CC (after dx): aspiration pna
Race, pertinent PMH, presentation to ED,
HPI.
-relevant ROS
-relevant ED issues (vitals, meds given)
-relevant things done o/n
-important events during hospitalizaton
11/20 – desat last night, improved after
diuresis
**Asp Pna – on cefepime, still
borderline
**ARF on CKD: Cr 0.8  2.5,
likely 2/2 dehydration. Getting
volume
**CAD – EF 10%, on coumadin
for low EF
**DM – on insulin
**HTN
**Hyponatremia – likely 2/2
dehydration
**Diarrhea – possibly CDIff, cx
pending
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS @
150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones 4442244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if Na
<130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation w/ air
bronchograms, some LAD
MICRO:
11/2 UA neg, Ur cx neg-final
11/2,3,4,5 bld cx x2 neg-final
11/6 UA neg, cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
---PMH---Prostate ca – resected, cured
-hyperlipidemia
-PTSD
-chronic anemia
Patient Information
Pt Info
Smith, John Bob
F14 1465A
MR: 34520984
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: DNR A
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
Automatically imported from SCM
Patient Information
Pt Info
Smith, John Bob
F14 1465A
MR: 34520984
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: DNR A
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
Start with name & status: If you are worried about the
patient, say it now - up front. Write it in the crosscover
section.
“John Smith is very sick” ; “I’m worried about Mrs
Jones”
Code Status: If not Full Code, always state this verbally.
“He is DNR A”
Access, Culture Limits, Precautions: mention if relevant
Contact information: Emergency contact for patient.
“This family wants to be called with every change or new
problem, even if in the middle of the night”; “No contact
person has been located yet for this patient with
dementia”
History & Relevant Data
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John Bob
F14 1465A
MR: 34520984
Age, Gender, CC (on DOA): short of breath
CC (after dx): aspiration pna
Race, pertinent PMH, presentation to ED,
HPI.
-relevant ROS
-relevant ED issues (vitals, meds given)
-relevant things done o/n
-important events during hospitalizaton
11/20 – desat last night, improved after
diuresis
**Asp Pna – on cefepime, still
borderline
**ARF on CKD: Cr 0.8  2.5,
likely 2/2 dehydration. Getting
volume
**CAD – EF 10%, on coumadin
for low EF
**DM – on insulin
**HTN
**Hyponatremia – likely 2/2
dehydration
**Diarrhea – possibly CDIff, cx
pending
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS @
150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones 4442244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if Na
<130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation w/ air
bronchograms, some LAD
MICRO:
11/2 UA neg, Ur cx neg-final
11/2,3,4,5 bld cx x2 neg-final
11/6 UA neg, cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
---PMH---Prostate ca – resected, cured
-hyperlipidemia
-PTSD
-chronic anemia
History & Relevant Data
HPI
Age, Gender, CC short of breath
CC: aspiration pna
Patient w/ shortness of breath for 1
week & 10 pound weight loss. Found
to have lung mass & post obstructive
pna.Vitals on adm to ED: 100 140/80
30 88% RA
11/20 – desat last night, improved
after diuresis
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
MICRO:
11/2 UA neg, Ur cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
Automatically imported from SCM
History & Relevant Data
HPI
Age, Gender, CC short of breath
CC: aspiration pna
Patient w/ shortness of breath for 1
week & 10 pound weight loss. Found
to have lung mass & post obstructive
pna.Vitals on adm to ED: 100 140/80
30 88% RA
History: State the chief complaint at first –
once you know the diagnosis, you should
UPDATE it. Short history. Admission vitals if
they are relevant.
“45 y/o female with abdominal pain”
“89 y/o male with pneumonia.”
11/20 – desat last night, improved
after diuresis
Important Hospital Events: Mention things
that could come up overnight
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
MICRO:
11/2 UA neg, Ur cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
“Desatted last night and responded to IV
lasix”
Data and Micro: Summarize findings,
do not cut and paste results!!
History & Relevant Data
HPI
HPI
45 y/o F w/ Shortness of breath
Too
45yo female with history of multiple
sclerosis, GERD, CAD, DM, hypothyroidism
brought in by husband after 5 days h/o
confusion, shortness of breath, and fever.
Initial CXR negative, however CT from 11/16
showed pna suspicious for aspiration. ROS
also notable for 10 pound weight loss,
anorexia, and fatigue over past 6 months.
Vitals on adm to ED: 100 140/80 30 88% RA
Got lasix x 2 , Cefepime/Flagyl, and
morphine in the ED. Duiresed in the ED to
lasix through not thought to be volume
overloaded by us.
Also has UTI on levo, foley now out
45 y/o F w/ Pneumonia
45 yo female admitted with shortness of
breath and confusion: suspected aspiration
pna. Also has 10 pound weight loss.
Vitals on adm to ED: 100 140/80 30 88% RA
DATA:
11/5 Chest CT: Heart, mediastinum, and great
vessels are normal. There is mild emphysema
throughout the lung fields, there is a left
lower lobe consolidation new since prior CT
from 1/06. Suspect aspiration
MICRO:
Wordy…
11/18 – UTI diagnosed – now on Levo
11/20 – desat last night, improved after
diuresis
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
MICRO:
11/2 UA neg, Ur cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
MUCH BETTER!
History
HPI
Age, Gender, CC short of breath
CC: aspiration pna
Patient w/ shortness of breath for 1
week & 10 pound weight loss. Found
to have lung mass & post obstructive
pna.Vitals on adm to ED: 100 140/80
30 88% RA
11/20 – desat last night, improved
after diuresis
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation
MICRO:
11/2 UA neg, Ur cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
Problem List
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John Bob
F14 1465A
MR: 34520984
Age, Gender, CC (on DOA): short of breath
CC (after dx): aspiration pna
Race, pertinent PMH, presentation to ED,
HPI.
-relevant ROS
-relevant ED issues (vitals, meds given)
-relevant things done o/n
-important events during hospitalizaton
11/20 – desat last night, improved after
diuresis
**Asp Pna – on cefepime, still
borderline
**ARF on CKD: Cr 0.8  2.5,
likely 2/2 dehydration. Getting
volume
**CAD – EF 10%, on coumadin
for low EF
**DM – on insulin
**HTN
**Hyponatremia – likely 2/2
dehydration
**Diarrhea – possibly CDIff, cx
pending
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS @
150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones 4442244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if Na
<130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation w/ air
bronchograms, some LAD
MICRO:
11/2 UA neg, Ur cx neg-final
11/2,3,4,5 bld cx x2 neg-final
11/6 UA neg, cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
---PMH---Prostate ca – resected, cured
-hyperlipidemia
-PTSD
-chronic anemia
Problem List
List all Active Problems: Include salient
points of plan and important results.
“For aspiration pna – patient is on cefepime,
10 day course. He also has renal failure &
hyponatremia – likely because of dehydration.
Diarrhea is concerning for CDiff”
Document Relevant Physical Exam Findings:
“Mr S. has dementia but is able to converse well
and can tell you if he is in pain”
“Mr J has CHF, her lungs always have rales..”
Chronic Problems: place chronic or inactive
problems at the bottom of the list
Prob List
**Asp Pna – on cefepime,
pox 98% 2L
**ARF on CKD: Cr 0.8 
2.5, likely 2/2 dehydration.
Getting volume
**CAD – EF 10%, on
coumadin for low EF
**Dementia-Ox1 but still
able to converse and give a
history
---PMH---Prostate ca – resected,
cured
-hyperlipidemia
-PTSD
-chronic anemia
Info is nice to have, but
too much! Makes the
prob list too long to sort
through in a rush
Summarize study in
the Data section.
Put relevance for
day to day care
here
Combine related
problems to save space
Problem List

Mention things that on-call interns have been called about
every night


“This patient sundowns every evening…and here is the plan should it
happen tonight…”
Review important exam findings and always think about
including mental status


“Mrs. J has severe asthma flare, lung exam is severe wheezing and
little air movement on exam today”
“Mr S.has dementia and only oriented x 1, but always able to follow
commands, tell you if he’s in pain, etc”
Medications
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John Bob
F14 1465A
MR: 34520984
Age, Gender, CC (on DOA): short of breath
CC (after dx): aspiration pna
Race, pertinent PMH, presentation to ED,
HPI.
-relevant ROS
-relevant ED issues (vitals, meds given)
-relevant things done o/n
-important events during hospitalizaton
11/20 – desat last night, improved after
diuresis
**Asp Pna – on cefepime, still
borderline
**ARF on CKD: Cr 0.8  2.5,
likely 2/2 dehydration. Getting
volume
**CAD – EF 10%, on coumadin
for low EF
**DM – on insulin
**HTN
**Hyponatremia – likely 2/2
dehydration
**Diarrhea – possibly CDIff, cx
pending
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS @
150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones 4442244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if Na
<130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation w/ air
bronchograms, some LAD
MICRO:
11/2 UA neg, Ur cx neg-final
11/2,3,4,5 bld cx x2 neg-final
11/6 UA neg, cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
---PMH---Prostate ca – resected, cured
-hyperlipidemia
-PTSD
-chronic anemia
Medications
MEDS
Automatically imported from SCM
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS
@ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
Medications
• Important Meds Should Be Verbally Reviewed &
Highlighted:
Antimicrobials, Anticoagulants, Narcotics, Benzos
“For pneumonia, patient is on cefepime, plus flagyl
for possible CDiff, and warfarin for a low EF.”
• Mention any important changes in meds:
New meds, Discontinued meds, Dose Changes
“For HTN he is on metoprolol, but we had to
decrease his dose today because of bradycardia.
So if he is hypertensive, I would use something
else.”
MEDS
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS
@ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
Medications
MEDS
Other med info:
Medications dosed by level,
ordered daily,
recent antibiotics,
abnormal reactions
For warfarin, use “warfarin dose
daily” order
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS
@ 150
---Other Med Info--Flagyl 500mg q12 11/2-4
D/C Info & To Do List
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John Bob
F14 1465A
MR: 34520984
Age, Gender, CC (on DOA): short of breath
CC (after dx): aspiration pna
Race, pertinent PMH, presentation to ED,
HPI.
-relevant ROS
-relevant ED issues (vitals, meds given)
-relevant things done o/n
-important events during hospitalizaton
11/20 – desat last night, improved after
diuresis
**Asp Pna – on cefepime, still
borderline
**ARF on CKD: Cr 0.8  2.5,
likely 2/2 dehydration. Getting
volume
**CAD – EF 10%, on coumadin
for low EF
**DM – on insulin
**HTN
**Hyponatremia – likely 2/2
dehydration
**Diarrhea – possibly CDIff, cx
pending
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS @
150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones 4442244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if Na
<130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation w/ air
bronchograms, some LAD
MICRO:
11/2 UA neg, Ur cx neg-final
11/2,3,4,5 bld cx x2 neg-final
11/6 UA neg, cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
---PMH---Prostate ca – resected, cured
-hyperlipidemia
-PTSD
-chronic anemia
D/C Info & To Do List
D/C Info – Outpatient MD information,
appointments to be made after
discharge, any discharge related item
To Do – Items for the primary team to
do (today or later in the admission)
Crosscover teams will look at this too
To Do
---D/C Info--PMD Dr. Jones 444-2244
[] needs gi appt
---To Do --[] f/u xxx test
[] check TEN panel weekly
[] daily pulm note
Crosscover Items
Pt Info
HPI
Prob List
MEDS
To Do
CrossCover
Smith, John Bob
F14 1465A
MR: 34520984
Age, Gender, CC (on DOA): short of breath
CC (after dx): aspiration pna
Race, pertinent PMH, presentation to ED,
HPI.
-relevant ROS
-relevant ED issues (vitals, meds given)
-relevant things done o/n
-important events during hospitalizaton
11/20 – desat last night, improved after
diuresis
**Asp Pna – on cefepime, still
borderline
**ARF on CKD: Cr 0.8  2.5,
likely 2/2 dehydration. Getting
volume
**CAD – EF 10%, on coumadin
for low EF
**DM – on insulin
**HTN
**Hyponatremia – likely 2/2
dehydration
**Diarrhea – possibly CDIff, cx
pending
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS @
150
---Other Med Info--Flagyl 500mg q12 11/2-4
---D/C Info--PMD Dr. Jones 4442244
[] needs gi appt
---To Do --[] f/u xxx test
[] daily pulm note
[] f/u 7pm Na –
increae IVF if Na
<130
-if looks bad,
consider fungal
coverage
DOB: 11/3/38
DOA: 11/2/06
Allergies: NKDA
Code: FULL
Access: RIJ 3L (11/4)
Cx: >101.4
Precautions: MRSA
Contact:
Wife Mary 215-7777777
DATA:
11/3 CXR: LLL pna
11/5 Chest CT: LLL consolidation w/ air
bronchograms, some LAD
MICRO:
11/2 UA neg, Ur cx neg-final
11/2,3,4,5 bld cx x2 neg-final
11/6 UA neg, cx neg-final
11/6,7,8,9 bld cx x2 ngtd
11/9 sputum cx – normal OP flora
---PMH---Prostate ca – resected, cured
-hyperlipidemia
-PTSD
-chronic anemia
Crosscover Items

BE SPECIFIC


Check box for each task you need done
Avoid vague statements


“try to keep an eye on…”
If you want vitals followed up on or
something “eyeballed” – make a separate
task for it
Crosscover Items
For Labs: give specifics
CrossCover
“Follow up on the 7p Na – he has been
hyponatremic and we think this is prerenal.
Increase his IVF if Na is still lower than 130.”
[] f/u 7pm Na - If
<130, then increase
IVF to 150cc/hr
Anticipatory Guidance: use If…then statements
“If he looks worse tonight (any fever, low BP, or
called for confusion), evaluate him and add
fungal coverage”
[]if any fever, delta
MS, or low BP, then
add vorizonazole
***SICK***
Write here if your patient is sick or if you are
worried about the patient
Tips for Cross-Cover Items


Discuss each crosscover task to be done,
why it is being done (rationale), and
what to do based on results (anticipatory
guidance).
Anticipate overnight clinical scenarios, and give
the cross-cover intern guidance on what to do if
they occur…If/Then statements

If the patient has a fever >101.5, then draw blood
cultures and consider starting vancomycin. We are
worried about a line infection
Give specific lab & parameters:
[] 1800 Hg – if <7, trf 2u PRBC
Give recs for meds to use:
-if not, t/c 80mg IV lasix
Give antibiotic
preferences to start
What are you looking
for?
Don’t get “locked in”
(anchoring bias)

Remember if/then statements are for guidance

You should still always:


EVALUATE the patient first
Then CONSIDER what they have recommended on
the sign-out. Independent thought is what you get
paid the big bucks for!
Don’t feel bad!!



We are all on the same team
You will be doing the same thing for your
colleague when you are on call
Be clear about what needs to be done


Avoid phrases like “If you can…”
Only signout out things that need to get
done overnight
Responsibility of the Receiver
Responsibility of the Receiver


READBACK & RECAP
 Reiterate important parts of the
plan
Take notes as you go

You will pay attention to these notes later
in the night
Responsibility of the Receiver

Be gently assertive!


Suggest a quiet place, suggest to sit down,
if the “giver” of the signout does not.
Do not be afraid to ask them to slow down




Similarly, do not let the receiver RUSH You!
Don’t be afraid to ask them to pay attention!
Do not be afraid to ask questions or repeat
If you are uncomfortable with a plan of care
that is signed-out to you, get both of your
residents involved.
Responsibility of the Receiver

Eyeball sick patients early in the evening


Get a baseline for their clinical status
Write down all events overnight to relay
the next morning
Responsibility of the Receiver
MEDS
•Circle or Highlight important issues on
the sign-out.
•For Medications:
Consider highlighting
pressors, antibiotics,
anticoagulants, narcotics
Prob List
**Asp Pna – on cefepime, still
borderline**ARF on CKD: Cr
0.8  2.5, likely 2/2
dehydration. Getting volume
**CAD – EF 10%, on
coumadin for low EF
**DM – on insulin
**HTN
**Hyponatremia – likely 2/2
dehydration
**Diarrhea – possibly CDIff,
Cefepime 1gm IV q12
Colace 100mg po bid
Docusate 5mg po daily
Furosemide 20mg po daily
Metoprolol 50mg po bid
Metronidazole 500mg po bid
Morphine SR 30mg po bid
Warfarin 5mg po qHS
Diet: Cardiac, mech grnd, NS @
150
---Other Med Info--Flagyl 500mg q12 11/2-4
Morning Handoff When on Call

Every call, or order placed should be
verbally reviewed


Write down all calls/issues/orders placed
on handoff while on call to serve as a
visual reminder the next morning
IMPORTANT: any changes in medications
or clinical status, new or pending results
When to update?

As frequently as possible


Less to do at the end of the day
Busy days:



Take notes on signout
Update at the end of the day
If cant get to it all, update the most
important info, and keep notes to update
the next day
Summary of
“Best Practices” in Handoffs






Quiet Location
Minimize Interruptions
Problem based verbal handoff
Standardize both written and verbal
format as much as possible
Use anticipatory guidance
Make time for questions and
clarifications
PRIVACY




Handoffs contain many patient
identifiers!
Do NOT leave the hospital with them
Do NOT leave them on tables, counters
or anywhere other than your hands
Old signouts should be placed in locked
containers for shredding
Questions?