Shift Handoff SBAR Audit

Nursing shift handoff inspection template to audit SBAR communication, safety items, pending tasks, and family updates during shift change.

Situation

• Patient identified using two identifiers
  Patient name and another identifier were stated or verified during handoff.
• Primary diagnosis or reason for admission stated
  Current diagnosis, admitting problem, or reason for hospitalization was communicated.
• Current condition and acuity summarized
  Current status, stability, and any acute changes were communicated in a concise, observable way.
• Vital signs or key trends reviewed
  Relevant vital signs, trends, or abnormal findings were included when applicable.
• Code status communicated
  Code status or resuscitation preferences were stated if applicable.

Background

• Pertinent medical history reviewed
  Relevant comorbidities, recent procedures, or baseline concerns were included.
• Allergies and precautions communicated
  Medication allergies, isolation status, fall risk, aspiration risk, or other precautions were stated.
• Relevant medications or infusions reviewed
  High-alert medications, titratable drips, anticoagulants, insulin, or other important therapies were discussed.
• Recent procedures, labs, or diagnostics mentioned
  Important results or completed procedures that affect current care were communicated.
• Baseline functional status or mobility needs reviewed
  Mobility level, assistive devices, or baseline cognitive/functional needs were included when relevant.

Assessment

• Pain assessment communicated
  Current pain score, location, and response to interventions were included.
• Respiratory and hemodynamic status reviewed
  Breathing status, oxygen needs, telemetry concerns, or hemodynamic instability were communicated when applicable.
• Lines, drains, airways, and access devices reviewed
  IVs, central lines, drains, catheters, oxygen devices, or other devices were verified and discussed.
• Safety risks communicated
  Fall risk, elopement risk, bleeding risk, pressure injury risk, or other active safety concerns were stated.
• Abnormal findings or unresolved concerns escalated
  Open clinical concerns, abnormal assessments, or changes requiring follow-up were clearly identified.

Recommendation and Pending Tasks

• Pending tasks were clearly listed
  Medications, treatments, labs, assessments, transport, discharge steps, or other tasks due on the next shift were identified.
• Time-sensitive items or deadlines communicated
  Tasks with specific due times, follow-up windows, or escalation thresholds were stated.
• Recommended plan of care reviewed
  Expected interventions, monitoring priorities, and anticipated next steps were communicated.
• Provider notifications or consult follow-up noted
  Outstanding calls, consults, or provider follow-up items were included.
• Escalation criteria or contingency plan stated
  What to watch for and when to notify the provider or rapid response team was communicated.

Family and Communication Updates

• Family or caregiver updates communicated
  Relevant updates shared with family, caregiver, or legal representative were included when appropriate.
• Patient education or teaching needs noted
  Education completed, reinforcement needed, or barriers to understanding were communicated.
• Interpreter or communication accommodations addressed
  Language needs, hearing/vision barriers, or other communication accommodations were noted if applicable.
• Questions from patient or family were addressed
  Outstanding questions, concerns, or follow-up items from the patient or family were acknowledged.
• Handoff completed with opportunity for questions
  The incoming nurse had an opportunity to ask clarifying questions before the handoff ended.