Care Transition and Handoff Documentation

Document the transfer of care information, medication status, and follow-up plan at a change in level of care to support continuity of care.

Patient and Transition Details

• Patient Identifier
  Use the facility medical record number or another internal identifier. Avoid collecting SSN or other unnecessary PII.
• Patient Name
  Enter the patient's full name for handoff verification.
• Date of Transition
  Select the date the level of care changed or the handoff occurred.
• Type of Transition
• Receiving Location / Provider
  Enter the name of the receiving facility, unit, provider, or care team.
• Reason for Transition
  Briefly describe why the level of care changed. Keep the summary concise and clinically relevant.

Clinical Summary and Current Status

• Current Condition Summary
  Provide a brief summary of the patient's current condition, stability, and any recent changes.
• Mobility / Functional Status
  Select all that apply to describe current functional needs.
• Diet / Nutrition Notes
  Document any diet restrictions, swallowing precautions, or nutrition support needs.
• Precautions / Alerts
  Select any active precautions or alerts that the receiving team should know.

Medication Reconciliation

• Medication Reconciled?
• Medication Changes Summary
  Summarize started, stopped, and changed medications. Do not include unnecessary sensitive details.
• High-Risk Medications
  Select any high-risk medication classes that require special monitoring or handoff attention.
• Medication Follow-Up Needed?
• Medication Follow-Up Details
  Describe any pending prescriptions, prior authorizations, monitoring, or clarification needed.

Follow-Up Plan and Pending Items

• Follow-Up Appointments
  Add each scheduled or recommended follow-up appointment.
• Pending Tests / Results
  List any labs, imaging, or consult results that are still pending at the time of handoff.
• Pending Tasks
  Select any tasks that must be completed after the transition.
• Responsible Party
  Identify who is responsible for the next action, if known.

Consent, Receipt, and Attestation

• Consent to Share Care Information
  Confirm that the patient or authorized representative has consented to sharing relevant care information as needed for treatment and coordination.
• Receiving Team Acknowledged Receipt
  Check if the receiving team confirmed receipt of the handoff information.
• Completed By
  Enter the name and role of the person completing this documentation.
• Completion Date and Time
  Record when the handoff documentation was completed.
• Attestation
  Sign to confirm the information is accurate to the best of your knowledge and that the handoff was completed according to policy.