Oman College of Health Sciences-North Batinah Branch
Clinical Handover Checklist
Student Name: _________________________________________Clinical Area: ___________
COMPETENCY CRITERIA PERFORMANCE CRITERIA Done Not Done
(1) (0)
1. Identity Patient Confirms patient identity (Check for 3 identifiers: Name, MRN,
DOB)
2. Gains Informed Consent 2.1. Gains informed consent from the patient (elements of
From Patient/Family consent considered)
2.2.Consider patients Age, below 18-consent must be provided
by parent
3.Introduction 3.1.Introduce yourself, your role and location
3.2.Identify the nurse/HCP present
3.3.Clearly identify/acknowledge patient and family if present
3.4. Maintains privacy and dignity all the time.
3.5. Use appropriate terminology
4.SITUATION 4.1.State the immediate clinical situation
(Provide concise description 4.2.State issues, concerns, or risks
of the patient’s current 4.3.Identify risks – Deteriorating patient, fall risk, Allergies,
situation) limitation to resuscitation
5..BACKGROUND 5. Provide relevant clinical history referring to medical record,
(Historical & current data such as: infectious status, invasive or implanted devices,
that are relevant to the medications, most recent observations, and test results.
patient’s current problem)
6.ASSESSMENT/ACTION 6.1.Assessment of the patient’s current situation
(A brief analysis of the 6.2. Refer to observations, medication, and other patient
situation based on charts (changes on patient’s conditions & management of
background data.) care i.e. IVF, NGT, medications etc.)
6.3. Summarize current risk management strategies
(MEWS, PEWS, fall assessment etc.)
7. RECOMMENDATION 7.1. Provide recommendation for the shift
(What is the nurse’s (Refer to medical record for any notable findings)
recommendation or what does 7.2.What further assessments and actions are required by who
she/he want?) and when
7.3.State expected frequency of observations
7.4.Request that receiver read back important actions required.
8. Evaluation 8.1. Allow patient and family an opportunity to ask question
8.2. Documentation: Record the name of the receiver, data, time
and communication using SBAR; the information performed and
the patient’s response to those interventions
MARKING: (Score/Total Score x 3%) /21 X 3% =
Note: Practice is REQUIRED before final marking (included in the CCA).
Comments: __________________________________________________________________
Signature of Clinical Supervisor: _______________________________________________
Signature of student: ________________________________Date: ____________________