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Run: Shift Handoff SBAR Audit

Audit nursing shift handoffs for complete SBAR communication, safety risks, pending tasks, and family updates. Use it to catch omissions before they become m...

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Situation

Patient name and another identifier were stated or verified during handoff.
Current diagnosis, admitting problem, or reason for hospitalization was communicated.
Current status, stability, and any acute changes were communicated in a concise, observable way.
Relevant vital signs, trends, or abnormal findings were included when applicable.
Code status or resuscitation preferences were stated if applicable.

Background

Relevant comorbidities, recent procedures, or baseline concerns were included.
Medication allergies, isolation status, fall risk, aspiration risk, or other precautions were stated.
High-alert medications, titratable drips, anticoagulants, insulin, or other important therapies were discussed.
Important results or completed procedures that affect current care were communicated.
Mobility level, assistive devices, or baseline cognitive/functional needs were included when relevant.

Assessment

Current pain score, location, and response to interventions were included.
Breathing status, oxygen needs, telemetry concerns, or hemodynamic instability were communicated when applicable.
IVs, central lines, drains, catheters, oxygen devices, or other devices were verified and discussed.
Fall risk, elopement risk, bleeding risk, pressure injury risk, or other active safety concerns were stated.
Open clinical concerns, abnormal assessments, or changes requiring follow-up were clearly identified.

Recommendation and Pending Tasks

Medications, treatments, labs, assessments, transport, discharge steps, or other tasks due on the next shift were identified.
Tasks with specific due times, follow-up windows, or escalation thresholds were stated.
Expected interventions, monitoring priorities, and anticipated next steps were communicated.
Outstanding calls, consults, or provider follow-up items were included.
What to watch for and when to notify the provider or rapid response team was communicated.

Family and Communication Updates

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

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