Ministry of National Guard - Health Affairs

Prince Muhammad Bin Abdulaziz Hospital

Al Madinah Al Munawwarah
Coronary Care Unit

Patient Case Presentation/ Handover Audit Tool

NO PERFORMANCE CRITERIA MET NOT NA COMMENTS
MET
Communication Tool
1. Was ISBAR used to structure communication in between staff-
to-staff endorsement during coverage (eg. when handing over to
cover break time)?
2. Was ISBAR used to structure communication during patient
case presentation with the change management team?

Introduction/ Identification
3.
Identity of person providing handover evident.
4.
Identity of individual(s), team receiving the handover.
5.
Identify of patient
Situation
6.
Location of patient mentioned.
7.
Brief summary of patients current status (e.g. state the
immediate clinical situation of the patient).
8.
State most important and recent observations (e.g. isolation
status: reason for isolation, updated culture).
9.
Was a problem identified?
Background
10.
Concise summary of reason for admission.
11. Provide relevant background/ history to the patients clinical
situation.
12.
State baseline observations (current admission; vital signs).
Assessment
13.
Evidence of patient assessment (e.g. state clinical assessment
of the patient at present).
14.
Identify assessments and actions that need to occur.
Recommendation
15.
Were recommendations made? (e.g. plan of care)
Handover Observation
16.
Uses ISBAR as core communication script and tools to
 document Clinical Handover.
17.
Conducts clinical handover on individual patients using verbal
face-to-face.
18.
Performed visual checking of the patient and their environment
by the person handing over and the person taking over care.
19.
Primary nurse receiving handover has comprehension,
acknowledgment and acceptance of responsibility for the patient
20.
Primary Nurse participate in medical-led clinical handovers (e.g.
medical team handover/rounds).
21.
Promotes the use of the patient record to cross-check
information.
22.
Primary Nurse routinely document in the relevant nursing notes
the fact that a clinical handover was conducted.

Date: __/__/___ Shift: _____ Name of Auditor: _________________ Sign/BN: __________