Written Handoff Assessment - Multiple - Robert Wood Johnson University Hospital

Service*

Acute Care Surgery
BEST
General Surgery
Pediatric Surgery
Surgical Oncology
Transplant Surgery
Urology
Vascular Surgery

Provider Type of Individual Giving Handoff*

Attending Physician
Advanced Nurse Practitioner
Physician Assistant
Physician Fellow
Resident Physician
Other

Other Provider

Day of Week*

Weekday
Weekend

Time of Day*

AM
PM

Written Handoff Assessment Tool-Multiple Patients

Indicate the frequency that each element of the mnemonic is present*

I. Illness Severity: Identification as stables, "watcher", or unstable; must occur at the beginning of each patient handoff. P. Patient Summary: Might include summary statement, events leading up to admission, hospital course, ongoing assessment, plan. A. Action list: To do list; (must be separated from patient summary). S. Situation Awareness/Contingency Planning: Know what’s going on; plan for what might happen. S. Synthesis by Receiver: Written reminder to prompt receiver to summarize what was heard during verbal handoff.

Indicate the frequency with which the provider who gave the handoff did the following.*

	Never	Rarely	Sometimes	Usually	Always	Unable to evaluate
Appropriately prioritized key information, concerns, or actions
To-do list restricted to items that need to be accomplished on next shift
High quality contingency plans with clear if/then format

Did you provide verbal feedback to the handoff team?*

Yes	No

Share one REINFORCING piece of feedback based on your handoff observation. No patient information should be entered into this form.

Share one CORRECTIVE piece of feedback based on your handoff observation. No patient information should be entered into this form.

Observer Name*

First Last

Technical Support

Written Handoff Assessment – Multiple

Written Handoff Assessment (Multiple patients)

Written Handoff Assessment Tool-Multiple Patients