Transfer of Care
Where is Hand off communication documented?
2.5 Hand off communication will be documented in the Electronic Medical Record (EMR) under the handoff tab on the navigator
True or False
Handoff communication shall not allow time for questions regarding the patient information since it has previously been verified.
True
2.1 All communication shall be interactive between the giver and the receiver
2.2 All communication shall allow time for questions regarding the patient information
EMR
Electronic Medical Record
Advanced Directive
5.3.10 The Operating Room RN and Preoperative RN will verify Advanced Directive if previously completed, is noted.
True or false
Scrub Nurse/Surgical Tech are not required to do a transfer of care report
False
5.5 Scrub Nurse/Surgical Technician transfer of care report shall include:
These 3 things must be verified during a handoff between the OR Nurse and Preop Nurse
5.3.2 Verify the patient has been assessed by the Anesthesia provider and documented
5.3.3 Verify the patient has been assessed by the Surgeon and documented 5.3.3.1 The surgical site is marked with the surgeon’s initials and visible
5.3.4 Verify the H&P has been completed. The H&P may be completed in advance, though no more than 30 days before the planned procedure or admission
True or False
A Signed interval note is needed if the H&P is greater than 48 hours. The note must be documented before the procedure begins.
False
5.3.5 A Signed interval note is needed if the H&P is greater than 24 hours. The note must be documented before the procedure begins
Policy Title: Hand-Off Communication
Handoff
Purpose
1.1 To provide accurate clear and complete information using interactive communication about a patient’s care, treatment and service, current condition and any recent or anticipated changes.
Needle localized cases requires verification prior to _______ to the __________
5.3.12 Needle localized cases requires verification prior to transport to the Operating Room (OR)
State when the Scrub tech would complete a transfer of care communication
Break relief, Lunch relief, change of shift
The Preop RN and Circulating RN will verify the informed consent and confirm these 4 things match the Consent, the Orders and the H&P
5.3.7 The Preop RN and Circulating RN will verify the informed consent and written consent information match the doctor’s order, H&P, and interval note
5.3.7.1 Confirm surgeon(s) name
5.3.7.2 Confirm procedure
5.3.7.3 Confirm laterality, if applicable
5.3.7.4 Confirm patient signature and date
True or False
Needle localized cases requires verification prior to transport to the Operating Room
True
5.3.12 Needle localized cases requires verification prior to transport to the Operating Room (OR)
LRHCDM
Patient/Legally Recognized Health Care Decision Maker
Preop medications
5.3.9 Verify the patient has been given preop medications and documented in medication administration record
Can you site this?
Effective communication processes for transferring patient information and care should include direct, verbal communication and use of standardized documents. 1. Effective verbal communication relies on the communication feedback loop and the steps of the communication process to ensure successful transfer of patient care
Guideline I Association of Surgical Technologist
Effective communication processes for transferring patient information and care should include direct, verbal communication and use of standardized documents. 1. Effective verbal communication relies on the communication feedback loop and the steps of the communication process to ensure successful transfer of patient care
Who can write and sign the interval note if the H&P is outdated (greater than required hours)
5.3.5.1 Can be written by
PA, NP, Resident/Fellow or Allied Health Care provider. This needs to be cosigned prior to the procedure.
True or False
All hand-off communication will utilize a standardized tool to ensure consistency and completeness of information transfer.
True
Policy Title: Hand-Off Communication
5.0 Provisions/Procedures. 5.1
Written Consent:
4.2 Written Consent: a form signed by the patient or LRHCDM which attests the informed consent discussion occurred with the physician/AHP and the patient/LRHCDM had an opportunity to ask and have their questions answered.
State how the OR Nurse and Preop nurse verify the surgical consent
5.3.8
The OR Nurse shall verify the surgical consent by conducting a visual and physical review of the consent form.
Concurrently, the Pre-Op Nurse shall verify the consent through the "Obtain Signed Consent Form" order on EMR.
RN Circulator Nurse transfer of care report shall include: Name 8 things
5.4.1 Patient’s Name
5.4.2 Diagnosis/Procedure being performed
5.4.3 Current stage of procedure
5.4.4 Recent changes in condition
5.4.5 Allergies
5.4.6 Medication/fluids on sterile field (labeled)
5.4.7 Medication pulled and being held
5.4.8 Specimens – currently obtained, and anticipated
5.4.9 Skin integrity
5.4.10 Tourniquet in use
5.4.11 Counts – items already opened / used items anticipated to be needed for the remainder of the case
5.4.12 Positioning and padding
5.4.13 Equipment in use
5.4.14 Estimated blood loss
OR Nurse transfer of care to PACU Nurse shall include: name at least 8 things
5.6.1 Patient’s name and Medical Record Number (verified from Identification (ID) band)
5.6.2 Diagnosis and pertinent medical history
5.6.3 Procedure performed
5.6.4 Allergies
5.6.5 Type of anesthesia administered
5.6.6 Estimated blood loss in OR
5.6.7 Intake and output
5.6.8 Any labeled drains and catheter status
5.6.9 Motor activity (neurological assessment) if applicable
5.6.10 Peripheral circulation issues
5.6.11 Positional issues
5.6.12 Skin integrity
5.6.13 Any additional issues or concerns (family, special needs)
True or False
Each surgical patients record shall consist of a nursing note that includes psychosocial and physical manifestations
True
5.3.11.1 Each surgical patient record shall consist of a nursing note that includes pertinent observations; including psychosocial and physical manifestations as well as incidents and unusual occurrences and relevant nursing interpretation of such observation
Informed Consent:
4.1 Informed Consent: an agreement or permission for treatment received after the patient/Legally Recognized Health Care Decision Maker (LRHCMD) is informed about the nature, risks, benefits, and alternatives of a procedure or treatment before the physician or other health care professional begins any such course.
Fill in the blanks
All communication shall be interactive between the ___ and the _____ .
Giver and Receiver
Scrub Nurse/Surgical Technician transfer of care report shall include: Name 8 things
5.5.1 Procedure being performed
5.5.2 Surgeon
5.5.3 Current stage of procedure
5.5.4 Medications / irrigation on sterile field (amount given)
5.5.5 Allergies
5.5.6 Location and count of all countable items currently in use
5.5.7 Instrument trays in use and counts of all instruments
5.5.8 Instrumentation special circumstances, when indicated
5.5.9 Disposition of specimens
5.5.10 Any additional issues or concerns
5.5.11 Implants as appropriate