Kingdom oF Saudi Ars w Segue ad iach Ministey of National Guan Health Anaits cS Ly Rymead g5) — stn aI) Appendix B —Intra-department Patient Handover-ISBAR-Checklist (Verbal Prompt Only) —___. Patient information to be considered for consistency and completeness of handover |, = Yourself give name, badge number and location % Patient —give full name I % Regsiver confirm 1 fme, badge number, pam ABT of patead ymca ger momber, pasion tithe — S + AKamission date %* Primary concern © Services required % Secondary concerns | Situation 6 Medical [surgical |”. nterventions/responses a » Code Status | | Background irae * Vita sgn metas pan * Respiratory + Infection control issues * Cardiac + Glucometer checks * GI/GU « ABGs * — Museuloskeleta! * Abnormal labs Assessment | Skin . + XR results + Psychosocial ae cae * Lines/fluids alls rs Nutrition risk Z Gana " |» Discharge needs ‘onsultations lesteissaiee » — Rdueation ic Bachar Recommendations | * ‘Test / Treatments she © This isa checklist only and not to be included in the patient's clinical record APP 1435-07: Patient Care Handover and Verbal/Telephone Com ication, March 2015 ~ Appendix BMinistry of National @ Before calling the physician: Saudi Arabin gel yh Sal r= Health Affairs Reet gg Lash ally Wey Appendix C ISBAR Handover Report to a Physician - Cheeklist (Verbal Prompt Only) Asors the patient Heview the chart for eppropriate plyscian to call nove the edaitng dass Fecal the most recem Progress Notes end assessment Ensure all petinen yformarion is aveiable before contacting the physician: Chat Allergies. Meds IY Mud, Labs: Results I Mentification Identify: You, Physician, Patient Is this Dr, ? State your name and unit Lam calling about: (Patient's Full Name, Age, Medical Record Number & Room Number) Why you are calling Jam calling because Background A Assessment Relevant background history State the admission diagnosis and date of adeaission State the poriinens medical history | A brief synopsis ofthe treatment fo date | State what you think the problem | Any abnor reclings from most recent vital signs : BP Pulse Respirations Temp p02 (patent is or és nav on oxygen) Any changes from prior assessment, such as = Mental status Respiratory rate / quality Reactions /use of accessory muscles Skin color ‘Neurological changes, inelading pain Wound drainage Musculoskeletal Goin deformity, weakness) GUGU (nausea/vomiting/diarrhea/output) R Recommendations State your recommendations - what you want the physician to do. ‘Ask for physician/consultant to come and review the patient Initiate some treatment or therapy “Transfer the patient to ICU or PICU ‘Talk to patient family ebout the code status ‘Are any tests needed? CXR / ABG / EKG / CBC / BNP Ifa change in treatment is ordered, then ask? How often do you want vital signs? Ypatient does nav impeave, when would you want us ro call again? This isa checklist onty and not to be included in the patient's elinieal record APP 1485.07: Pationt Care Handover and Verbal/Telephone Communication, March 2018- Appendix ©ysgaual dual Saal eval gill = pul usa la 2 Kingdom of Saudi Arabia X / Minisyof atonal Guard Heath Acs SOSA _Inpatient Transfer Form Daten TH -Tansferted from (Department: Pere Transfer NUse NIE face nnnnennnennmnen BAO. ee Receving NUISE NAM nnninnnnnnnninnnniiiniinn — BADGENO, minnie SIQRARUE! nnn Situation & 8 - Background Patient 1D wistband checked and corect Yes No | Diagnosis: NoCodestaus Ch Yes (No Most Recent Analgesia (dose & time Recent SurgeryProcedure: Allerg: Modical History Equipment / Documentation Received cee tabReuts Dyer One wa Pole $0 ecication a Adminstration Record © Yes C1 ne TWA ae ane Patents Cloting Yes One OWA roa eee Patents valuables 1 YesCNe GWA / - reece Xray /CT MRE O ves Ono Ona BSL ee -nnsnnstnnnnawenns | WediclRecoréeallvotes Cl YesCINo INA CUTER Weg nn — Othe nnn EOS nical Record Form Rev ODROIS _—ReFWAPP\4R5-7 Page Tor ‘Appendxh Oracle 118701, 086+ 01-0007AcAssesement Cardiac / Respiratory Systems ECG Completed Ores Oo CNA Cardiac Monitoring Required Dyes ONe CNA Comments ‘Oxygen Required ves ONe Ona Volume vx Delvery Device: nn Tracheostomy ElYes GINO Dateinserted: Cuffed Ores No SiR ic “Gastrointestinal /Renal Systems /Nutrition Eating Drinking Yes C1No Fluid Restriction 2 Yes C1 No [3 Volume nmnnnn Comments: Last Bowel Action FoleyCatheter C1 Yes CINo Dateinsrted sr Ties FINe DateInserted annem Pes Des EINe Dateinsered.. Colostomy Yes CIN@ Datetnseted an Comments Integumentary /Invasive Lines Functional Assessment Wound or Pressure Aras Ove Ne comments i cece — site Yes C)No Date sere nnn nt Infusion i Pat nnn HE Inf8002 nner rae rhe Infusions mune Comments pee Conwaltine Ye FINO Date Inter nnnnons Ponacaty — Eves C1 No Dae net enn chestTube Yes CINo Dateinserte.. AvFitula Yee No ate nerted ann Net none EBYes ELNo Date inerte : Mbizaion CI] Independent [1] Wheelehar)B Mose Transfers: Clindependent C)Assstx1 C2 Assist x2 Mots Showering: Clindependent C) Assistxt Cl Asistx2 Dresing: Clindependent C) Ast Fting: Independant C7 assists 1 false tow Medium High Henrng Impare Dye Ne Sight pat Dv Ono R- Response & Recommendations Cinical Record Form few 0272015 Rel VAPPIA35-07 Page 20f2 ‘race #118707, 08N¢ 0107-0001