Nursing Documentation

Question 1

What is the process for correct bedside handover?

Answer 1

• Hand hygiene
• introduce all nurses and patient (I)
• confirm patient ID
• use standard documentation
• relevant history of patient (S)
• detailed observations of patient (O)
• any other relevant background of patient (B)
• include patient in handover, allow them to ask any questions
• includes plan for upcoming shift and towards discharge (A)
• incoming nurses review patient notes, particularly last obs and medications
• patient and incoming nurses confirm they understand the plan, readback (R)
• outgoing nurse officially transfers care to incoming nurses, who officially accept it
• patient comfort, call bell
• hand hygiene

Question 2

What information do you include in the isobar?

Answer 2

• Identity - yourself (name, position) and the patient (name, age, gender, UMRN)
• Situation - when patient was admitted, what for, what their current situation or complaint is
• Observations - vital signs (highlighting abnormal results) at what time. Other relevant obs from assessment (eg - sweaty, description of wounds, consciousness level, etc)
• Background - any additional relevant information, patient or family concerns, etc
• Agreed plan - say what you have done (I’ve paged the MO), and what you want done (can you follow up the MO?…)
• Readback - mostly for verbal handover - making sure the receiving healthcare worker has understood anything by having them repeat key info. If written, this is where you read over, make sure it’s signed, dated and designated, is legible and makes sense and doesn’t omit any pertinent info