ASSIGNMENT

HAND OVER AND

TAKING OVER REPORT

Submitted To: Mrs.Raj Laxmi Submitted By: Ms. Meena Kumari

Tutor M.Sc. Nursing II Year

Clinical Handover

Definition of terms
  Clinical handover: Transfer of professional responsibility and accountability for some or
all aspects of care for a patient, or group of patients, to another person / family / legal
guardian or professional group on a temporary or permanent basis
 ISBAR: acronym that stands for Identification – Situation – Background – Assessment –
Recommendation/Response
 Group handover: may be facilitated as a large group with all nurses commencing the
shift and/or within smaller groups of nurses working together in a pod
 Bedside handover: direct patient handover that occurs at the patient’s bedside and
includes patients and parents/ carers 
 EMR Review: process of working through the EMR activities to collect pertinent patient
details

Management Responsibilities 
The Nurse Unit Manager’s (NUM) has responsibility for compliance with the clinical handover.
The operational leadership of handover and allocation of nurses to patients is usually the role of
the Associate Unit Manager (AUM). 

The NUM and/or AUM has the responsibility to ensure that the following principles are applied: 

 Patient care, as required, continues while handover is occurring

 The Electronic Medical Record (EMR) is available for nurses
 The venue, starting times and duration of the handover are set
 Group handover reflects time available and clinical demands of the shift (e.g. large group
with all nurses commencing their shift or in smaller groups of nurses working in a pod)
 Nurses have a clear understanding of the structure and expectations of handover
 Disruptions are minimised
 All relevant nurses attend handover
 ISBAR is the format used to structure communication 
 Allocation of patients to suitable competent nurses   
 Audits of the handover process are completed as required

Clinical Handover

Group Handover (inpatient, ward based)

 Occurs every day at the time of the shift change-over or start of shift
 Takes place in a designated area 
 All nurses, including student nurses, commencing a shift attend the group handover 
 Group handovers are led by the AUM in charge of the shift 
 ISBAR format applied to structure handover (EMR handover report function may be
useful) 
 Handover is respected with minimal disruptions (no mobile phones or pagers to be
answered)
  At the conclusion of group handover, any important messages pertaining to the ward or
hospital are discussed e.g. staffing, potential issues relevant to running of the unit
 Group handover is completed allowing adequate time for bedside handover before nurses
finish the previous shift
 Handover for nurses working in the community allows adequate time to review all
documented handovers

Bedside Handover (inpatient, ward based)

 Handover occurs by each patients’ bedside including patients, parents/ carers 

 Handover occurs between the nurse that holds responsibility for care and the nurse who
will be assuming responsibility for the care of the patient
 Positive Patient identification process occurs during bedside handover confirming full
name, date of birth and Medical Record Number (MRN) to the EMR as per the RCH
Patient Identification Procedure
 Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions) 
 ISBAR format is applied to structure handover 
 Patients and parents/ carers are encouraged to participate in bedside handover and be
aware of the plan of care for the next shift
 Patients, parents/ carers and nurses are encouraged to utilise the communication boards in
the patient room as a tool for handover between the multidisciplinary team 
 The handover is documented within EMR  
 Following handover at the bedside, an EMR review takes place
 In specified clinical areas (e.g. Wallaby & Pre-op Hold) direct patient care handover may
only occur in electronic documentation within the EMR 

Break Handover (inpatient, ward based)

 Handover occurs between the nurse that holds responsibility for care and the nurse who
will be assuming responsibility for the care of the patient
 ISBAR format is utilised to structure handover focusing on ISR – identification of the
patient, current situation and any risks or recommendations for break interval 
 The handover is documented in the EMR 

Transfer of patient within the hospital (for procedure, treatment or to another ward)

 All patients transferred to from one clinical area to another clinical area require handover
to be documented in the EMR. This includes details of the transfer time indicating a
transfer of professional responsibility and accountability
 Positive Patient identification process occurs to confirm full name, date of birth and
Medical Record Number (MRN) to the EMR as per the RCH Patient Identification
Procedure
 Clinical alerts are identified (e.g. FYI flags, allergies, infection control precautions, MET
modifications) 
  The handover is documented in the EMR 
 A patient can be transported by CARPs, parents/ carers if the patient is assessed as:

 Stable
 Predictable 
 Having no fluids or blood product transfusions running
 Requiring clinical observations <4 hourly
 Handover can be conducted over the phone to the receiving nurse/ AUM/
appropriate health practitioner who will then assume responsibility and
accountability for the patient 
 A patient must be escorted by the nurse if the patient is assessed as:

 Unstable
 Having fluids or blood transfusions running
 Requiring clinical observations <4 hourly
 Handover occurs between the nurse that holds responsibility for care and the
nurse who will be assuming responsibility for the care of the patient
 Inpatients to theatre

 Handover occurs between the nurse that holds responsibility for care and the pre-
op hold  nurse who will be assuming responsibility for the care of the patient
 Rosella and Butterfly patients to theatre


For Rosella inpatients being transferred to & from theatre, clinical handover is
required from the bedside nurse to the anaesthetist 
 Ambulatory Care patient to another clinical area

 The nurse transferring care contacts the relevant AUM of the receiving clinical
area to ensure patient is expected and handover is given
 Relevant local administrator (Desk Staff, Ward Clerk) to be notified of transfer or
admission by the AUM

Non Clinical Activities

 Parents, carers, teachers, volunteers etc. can escort a patient off the ward if they have
been assessed as safe to leave the ward without a nurse as per the Supervision and
movement of inpatients across RCH and access to inpatient areas procedure
 If the patient is deemed safe without a nursing escort document in the EMR

NB Patients colonised with a multi-resistant organism may only leave ward/room with
agreement by treating team or Infection Prevention and Control  

Patient Discharge
  On discharge home patients are provided with written discharge advice about the
patient’s hospital stay
 An After Visit Summary (AVS) can be printed for the parents/ carers, along with any
attendance certificates, which has a minimum data set including: 

 name of consultant
 diagnosis
 medication plan 
 follow up information 
 phone number to contact if more information required 
 The clinician documents in the EMR that the discharge advice has been given to the
parents/ carers and the time of discharge. 

Companion documents 

 Policy and Procedures

 Patient and Family Centered Care (procedure)

 Governance (policy)
 Consumer Focused Care (policy)
 Patient Identification (procedure)
 Clinical Handover (procedure)
 Infection Prevention and Control and Disease Outbreak (policy)

 Supervision and movement of inpatients across RCH and access to inpatient areas
Procedure Transmission based precautions (procedure)

 Multi resistant organisms (procedure)

DAY AND NIGHT REPORT /HANDING OVER REPORT MAINTAINED BY HAHC

s.no Present New Admission Discharge Transfer Lama Death total

patient
Morning 4 1 - - - - 5
Evening 5 - - - - - 5
Night 5 - - - - - 5

Handing over by :Sr.priya Handing over by :Sr.Rita Handing over by :Sr.Meena

Handover given by:Sr.Rita Handover given by:Sr.Meena Handover given by:Sr.Anu

Patient details:-

Patient Ipd Diagn Unit Diet Treatment Mornin Eveni Night

Name No. osis g ng

Hema 6134 Sob 4 Hosp Urine Urine Pleura Sputum

itall Routine,Pleural Rounti l Tap Sent ,
Diet Tap, Sputum, ne Sent Done Pleural
Fundus tab
report
awaited
Munni 6139 T2dm 4 Hom Usg W/A,Urine USG Iron
Devi e Routine ,Iron done profile
Diet Profile Urine sent
sample
sent
Barfo 5913 Dm 3 Hosp Diet Reference Sent
Devi ital
Diet
Shanty 6181 Epiga 2 Hom New Admission All Report
stric e Routin collecte
Pain e d&
Investi informe
Sent d to
doctor
Vimla 6131 Htn 5 Hos Usg – Gyanre
W/A,Fundus,Spu Referen
tum Afb,Gyane ce
Reference Pending
Reference :

 National Safety and Quality in Healthcare Service Standard 6 – Communicating for

Safety Standard. ACSQHC, 2019. (Accessed 16 May
2019 https://nationalstandards.safetyandquality.gov.au/topic/user-guide-acute-and-
community-health-service-organisations-provide-care-children/communicating)
 National Safety and Quality in Healthcare Service Standard 3 - Preventing and
Controlling Healthcare-Associated Infections. ACSQHC, 2019 (Accessed 16 May
November https://nationalstandards.safetyandquality.gov.au/3.-preventing-and-
controlling-healthcare-associated-infection)