Effective communication among healthcare professionals during hand-off reporting is essential to delivering safe and continuous patient care. Common professional interactions include reports to healthcare team members, hand-off, and transfer reports. Nurses routinely report information to other healthcare team members and also urgently contact healthcare providers to report changes in patient status.

Standardized methods of communication have been developed to ensure that information is exchanged between healthcare team members in a structured, concise, and accurate manner to provide safe patient care. One standard format healthcare team members use to exchange patient information is SBAR. Some hospitals expand on the mnemonic and use ISBARR for Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

  • Introduction: Introduce your name, role, and the agency you are calling from.
  • Situation: Provide the patient's name and location, why you are calling, recent vital signs, and the patient's status.
  • Background: Provide pertinent information about the patient, such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
  • Assessment: Share abnormal assessment findings and evaluation of the current patient situation.
  • Request/Recommendations: State what you would like the provider to do, such as reassess the patient, order a lab/diagnostic test, prescribe/change medication, etc.
  • Repeat back: If receiving new orders from a provider, repeat them back to the provider to confirm accuracy. Be sure to document communication with the provider in the patient's chart.

Although many types of nursing shift-to-shift hand-off reports have been used over the years, evidence strongly supports that bedside hand-off reports increase patient safety and patient and nurse satisfaction by effectively communicating real-time, accurate patient information. Bedside reports typically occur in hospitals and include the patient, the off-going, and the oncoming nurses in a face-to-face hand-off report conducted at the patient's bedside. HIPAA rules must be kept in mind if visitors are present or the room is not private. Family members may be included with the patient's permission. Although a bedside hand-off report is similar to an ISBARR report, it contains additional information to ensure continuity of care across nursing shifts.

Disclaimer: This text is adapted from Nursing Fundamentals, Open RN, Section 2.4, Communicating With Health Care Team Members

Tags
SBARISBARRHealthcare CommunicationHand off ReportingPatient CareNursing ReportsStandardized CommunicationBedside Hand offPatient SafetyNursing Shift ReportHIPAA CompliancePatient Information Exchange

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