1. Start 2. Prayer 3. Census 4. Patient-patient Endorsement 5. Quick rounds 6. End of endorsement

1. Cardex 2. Doctor’s Order Sheet 3. Medication Administration Record Sheet 4. Vital Signs Sheet 5. TPR Graphing Sheet 6. I & O Monitoring Sheet 7. IV Flow Sheet 8. Nurse’s Bedside Notes

DAY 2 Flashcards by Deleted Deleted

Handover Objectives

● Provide patient-quality care
● Improved better communication
● Improve implementation of nursing care
● Ensure doctor’s queries and patients
needs are addressed properly and
promptly

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According to _________, a Handover
requires a nurse to
● Communicate objectively, appropriately,
and concisely with other health
professionals;
● Understand and use medical or nursing
terminology
● Interpret charts and other documents
● (Write up?) patient observations, and
understand clinical procedures.

Flinders University

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According to Flinders University, a Handover
requires a nurse to:

● Communicate objectively, appropriately,
and concisely with other health
professionals;
● Understand and use medical or nursing
terminology
● Interpret charts and other documents
● (Write up?) patient observations, and
understand clinical procedures.

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Endorsement Flow

Start
Prayer
Census
Patient-patient Endorsement
Quick rounds
End of endorsement

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Before the handover, the nurse must
ensure that the ________ has been
done

tabulation of the departmental census report

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The nurse shall read the entries from
the _________ of the
departmental census to the incoming
nurse

end-of-shift report

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Handover Responsibilities
Bedside Nurse to Bedside Nurse
Outgoing Nurse:
Before Endorsement

Shall ensure to close all charts prior to
endorsement
Shall ensure and countercheck all
documentation was duly signed
Make sure that all the orders within the shift
were carried out, transcribed, encoded, and
performed
Shall perform a final chart review of the handled
patient’s chart for any pending tasks and
documentation

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Handover Responsibilities
Bedside Nurse to Bedside Nurse
Outgoing Nurse:
During Endorsement

Shall endorse all pertinent data to the incoming
nurse.
Shall back read doctor’s order within 48 hours
as part of the endorsement.
Shall perform comparative endorsement.
Ensuring all pertinent data was transcribed
correctly to the different nursing standard forms.
Shall follow the standard flow of endorsement of
the contents of the patient chart.

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Handover Responsibilities
Bedside Nurse to Bedside Nurse
Outgoing Nurse:
After Endorsement

Quick Rounds
Bid goodbye to the patient.
Update all information boards and Directory

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Basic Flow

Cardex
Doctor’s Order Sheet
Medication Administration Record Sheet
Vital Signs Sheet
TPR Graphing Sheet
I & O Monitoring Sheet
IV Flow Sheet
Nurse’s Bedside Notes

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Using a chart is requisite during the
entire endorsement process. T or F?

True

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Back reading of the doctor’s order must
begin ___hours prior to the latest order.

48 hrs

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_____________ must be
done for newly ordered medicine to
ensure complete transcription to
medication administration record

Comparative endorsement

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Nursing Assistant Procedures

● VS, CBG, I & O monitoring
● Patients who need extra care like
changing diapers, ambulation, or enteral
feedings
● Inventory of IME, Departmental assets,
crash carts
● For completion of unfinished errands
like NF medicine, CM, borrowed
supplies, and post charges.

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In absence of the clinical coders and nursing
assistants, who shall perform their
role?

the bedside nurse

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Handover Using Cardex:
Attending Physician

● Consent
● RIC informed/aware
● Encoded to system
● HMO accredited
● House/Private case

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Handover Using Cardex:
Laboratories Procedure

● Encoded/to encode
● To be performed
● Pending result
● Result released (referred)

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Handover Using Cardex:
Monitoring

● VS, NVS, CBG Frequency
● Abnormal - Referred to
● Weight, abd. Girth, pain scale

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Handover Using Cardex:
Patient Safety

● Fall Tool Assessment
● History of Fall
● Signages

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Handover Using Cardex:
IV Fluids

● On-going IVF
● IVF rate, level, number
● Side drip, cycle number
● IVF to follow
● IV site and due

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Handover Using Cardex:
Diet

● Allergies (labeled)
● Progression (To inform)
● Religion
● Restriction

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Handover Using Cardex:
Contrapments

Drains (FC, colostomy, IJ, cystoclysis)

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Handover Using Cardex:
Machines

● Cardiac monitor
● Pulse ox
● Telemetry

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Blood Products

● Type of blood
● # of available units or to secure
● Blood typing
● Compatibility
● No. of blood transfused

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Important Qualities During Endorsement

1. Communication 2. Punctuality 3. Conscientiousness 4. Comprehensiveness

Handover Using E-SBAR

Situation Background Assessment Recommendations

Handover Using E-SBAR Situation

● Diagnosis ● Current issues

Handover Using E-SBAR Background

● Medical history ● Previous Labs and Treatment ● Psychosocial Issues ● Allergies ● Code Status ● Physical Assessment ● VS ● Line Set ● IV Drips ● Assessment Ventilator Settings

Handover Using E-SBAR Assessment

● Drains ● Tubes ● Diet ● ADL’s ● Restrictions ● Wound Assessment and Care ● Laboratories ● Response to Treatment & Care ● Family Updates

Handover Using E-SBAR Recommendations

● Plan of Care ● Needs to be Attended ● Pending Orders ● Discharge Planning ● Issues ● Barriers

charge nurse/ clinical coder sheet

The distribution of patient assignments shall be based on

patient acuity score

shall ensure that the patient is equally distributed to the incoming nurse

charge nurse/ clinical coder

● The ----- sheet log in to the HMS application and shall do patient assignments for the incoming nurse ● The distribution of patient assignments shall be based on the patient acuity score ● The ----- shall ensure that the patient is equally distributed to the incoming nurse ● Once the patient is equally distributed, the electronic SBAR shall be printed ● The printed SBAR shall be handed over to the incoming Bedside Nurse based on the distribution and patient assignment ● The E-SBAR tool shall be used during handover.

Charge Nurse/Coder

1. The nurse shall compare the written orders if it is correctly transcribed in the nursing standard forms 2. After reading the doctor’s order, the nurse must have to look into the transcribed order and check for its correctness 3. The nurse must see to it that the orders are carried out accordingly. 4. The outgoing and incoming nurse shall review the contents carefully during the endorsement 5. If found erroneous, it must be corrected immediately. The correct order must be followed and transcribed accordingly. 6. The findings shall be reported to the charge nurse, unit manager, or to the supervisor on duty for documentation and filling in the OFIRS

Comparative Endorsement

From the doctor’s order sheet where to compare: ● Medication Order

MAR sheet

From the doctor’s order sheet where to compare: ● Vital Sign Order

Vital sign sheet/ TPR graphing Sheet

From the doctor’s order sheet where to compare: ● I & O monitoring

Cardex/ I & O monitoring sheet

From the doctor’s order sheet where to compare: CBG monitoring

CBG monitoring sheet/ cardex

From the doctor’s order sheet where to compare: Referral and co-management

Cardex

From the doctor’s order sheet where to compare: Special Endorsement-

Cardex

From the doctor’s order sheet where to compare

● Medication Order ● Vital Sign Order ● I & O monitoring ● CBG monitoring- ● Referral and co-management ● Special Endorsement

are important and pertinent data that need to be communicated to all healthcare teams

Special endorsements

part of the special considerations and precautions in managing the care of the patient

Special Endorsement

What to do during quick rounds

1. Introduction 2. Assessment 3. Orientation 4. IV rounds 5. Outroduction

The outgoing nurse shall bring with them a whiteboard marker and an eraser to be used for updating the

patient information board

● Inform the patient that your shift has ended and you will be handling over the care to the incoming nurse ● Introduce the name of the incoming nurse

Introduction

● Quickly assess the status of the patient and simple “kamustahan” with the patient. Ask the patient about his/her current state ● Perform an environmental assessment including safety measures

Assessment

● Inform the patient of the plan of care of the day. Update the Patient Information Board ● Orient the patient on the pending laboratories and diagnostic procedures that are to be done within the day (including the preparations needed) and other significant information

Orientation

● Initially assess the IV status of the patient (IV level, rate and etc.) ● Check for the IV site of the patient following the standards of VIP scoring ● Ensure that the IV site is examined from proximal to distal ends.

IV rounds

● The outgoing nurse shall bid goodbye to the patient ● The incoming nurse shall inform the patient that he/she shall be back after the quick round to administer the due medicines and bedside care.

Outroduction

The hung Door Signages shall coincide with the received endorsement

I. Fall prevention II. Food allergy III. Other Special Reminders

Door Signage (DRUG AND FOOD ALLERGY)

❖ Drug allergy ❖ Food allergy ❖ Food & Drug Allergy

Door Signage (FALL PREVENTION)

❖ Low Risk (yellow) ❖ Moderate Risk (orange) ❖ High Risk (red)

Door Signage (ISOLATION PRECAUTION)

❖ Droplet Precaution (red) ❖ Standard Precaution (yellow) ❖ Airborne Precaution (green) ❖ Protective Precaution (black) ❖ Contact Precaution (blue)

Door Signage (OTHER IMPORTANT REMINDERS)

❖ Visitors allowed ❖ Complete Bed Rest ❖ No Blood Taking at Left/Right Arm ❖ No Blood Extraction at Right/Left Arm

HOSPITAL STANDARD FORMS

a. Emergency Room Nurses’ Bedside Notes b. Adult Venous Thromboembolism (AVT) Risk Assessment Too c. Consent for Referral d. Informed Consent for IV Therapy e. Referral and Consultant Report f. No Heroic Measures (NHM) / Do Not g. Release from Responsibilities for Extubation h. Medication Administration Record i. IV Flow Sheet j. I&O Monitoring Stret k. Morse Fall Risk Assessment Tool l. Braden Scale m. VAP and Non-VAP Prevention Bundle n. Vital signs Sheet o. TPR Graphing Sheet p. Neuro Vital Sign Sheet q. CBG Monitoring Sheet r. Humpty Dumpty Scale s. Pressure Ulcer Scale for Healing (PUSH) t. Release from Responsibility for Discharge u. Pre-op Checklist v. Informed Consent to Medical and Surgical procedure w. Request For Transfer of Patient x. Request to Transfer to other Department y. Nurses Bedside Notes

Allergies must be written in ____ ballpen if present

RED

All procedures in ER are

STAT

Adult Venous Thromboembolism (AVT) Risk Assessment Tool

i. Low Risk ii. Moderate Risk iii. High Risk

1. Prophylaxis not required 2. Early mobilization 3. Patient education

i. Low Risk

1. Pharmacological option 2. OR Mechanical device

Moderate Risk

1. Pharmacological option 2. AND Mechanical device needed

High Risk

Some forms must be renewed accordingly AVT ward is ?

q5 days

Some forms must be renewed accordingly AVT critical is ?

q3 days

Used to refer patient to another physician

Consent for Referral

1 day service

Consultation

same duration as main MD

Co-managemen

Referred MD will start when Previous MD transfers duty

Transfer of service

No Heroic Measures (NHM) / Do Not Resuscitate (DNR) Form Big Four:

1. NO CPR 2. NO Intubation 3. NO Assisted Ventilation 4. NO Defibrillation

i. Can serve as guide for the contents of informed consent to medical and surgical procedure ii. BN will only fill out the “Floor Nurse” side

Pre-op Checklist

Bedside Nurse Problem Identification

a. Actual b. Procedures c. Treatment d. Outcomes/Remarks e. Time f. Problem g. Interventions h. Evaluation

COMPLETENESS AND FILLING UP a. Standard Forms

i. Complete Headings ii. Food & Drug Allergies (RED Ink) iii. Date & Time iv. Accurate Data & Assessment Records v. Real-time Monitoring vi. Problem Identified vii. Referral Notations viii. Complete Name & Signature

Significant Notation a. Blood Transfusion

i. Time BT Started ii. Type of Blood iii. Serial Number iv. Transfusion Rate v. Due Time vi. Level of Blood Components Received

Significant Notation b. Refusal

i. Name of Drug ii. Dosage iii. Time iv. Reason of Patient v. Let the patient/watcher write at the doctor’s order to show legibility with three signatures.

i. Usually done at ER, except for direct to room patients ii. No need for new consent if dislodged iii. Also can be used for CT Scan with contrast dye.

. Informed Consent for IV Therapy i. Usually done at ER, except f

i. Used by previous MD for the Consulting Physician to be used ii. CONSULTANT – written as “rounds with…” iii. DO NOT carry out orders written in this form

Referral and Consultant Report

i. Signed by consenting person ii. Should Not be left blanked; No erasures iii. Big Four: 1. NO CPR 2. NO Intubation 3. NO Assisted Ventilation 4. NO Defibrillation iv. Renewed every 3 days (considered full code if not renewed) v. No NHM at ICU!!!

No Heroic Measures (NHM) / Do Not Resuscitate (DNR) Form

Signed by consenting person to confirm removal of intubation and life support systems

Release from Responsibilities for Extubation

i. Records of all the medications of the pt. ii. Do NOT write food allergies iii. Not known allergies should still be written as NO KNOWN ALLERGIES iv. Recopied forms are placed on top

Medication Administration Record

i. If IV fluid did not finish when received at WARD, write the time finished in ER form then #2 on IV sheet ii. If Blood Transfusion, use or write the serial number.

IV Flow Sheet

Done every shift, admission, and sensory changes (maybe associated with fall)

Morse Fall Risk Assessment Tool

i. If with pressure ulcer, different sheet will be used ii. Done by AM shift only

Braden Scale

Fall risk scale for children

Humpty Dumpty Scale

if with a pressure ulcer.

Pressure Ulcer Scale for Healing (PUSH)

for Home Against Medical Advice (HAMA)

Release from Responsibility for Discharge

i. Can serve as guide for the contents of informed consent to medical and surgical procedure ii. BN will only fill out the “Floor Nurse” side

Pre-op Checklist

DAY 2 Flashcards

(88 cards)