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Shift Report & Bedside Transition

SBAR Handoff Template: Shift Report & Bedside Transfer

Standardize shift-to-shift nursing handoffs, change of shift reports, and inter-unit patient transfers. Structured communication eliminates omitted clinical cues and protects continuity of care between oncoming and outgoing healthcare teams.

Bedside Shift Handoff Example

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Clinical FrameworkRoutine

Med-Surg Shift-to-Shift Bedside Handoff

Standardized transition of care between outgoing and oncoming nurses

Patient: Eleanor Wright (71yo F)
Bed/Room: Room 204-B
MRN: MRN-449102
Attending: Dr. Foster
S

Situation

Immediate clinical concern & reason for calling right now

• Patient: Eleanor Wright (71yo F) in Bed 204-B. • Admitted 2 days ago s/p elective total abdominal hysterectomy. • Primary Team: Dr. Foster (Gynecologic Oncology). • Code Status: Full Code. Allergies: Sulfa drugs (Hives).
B

Background

Relevant clinical history, admitting diagnosis, medications & baseline

• History: Hypertension, Stage 2 Chronic Kidney Disease, Osteoporosis. • Surgical Course: Uncomplicated TAH. Foley removed 06:00 today. • Access: 20G PIV left forearm (placed 2 days ago, patent with D5 1/2NS + 20 mEq KCl @ 75 mL/hr). • Pain Control: Switched from PCA to Oral Oxycodone 5-10 mg Q4H PRN + Scheduled IV Acetaminophen.
A

Assessment

Current vital signs, objective physical findings & clinical interpretation

• Neuro: Alert, oriented x4, pleasant and cooperative. • Vitals: BP 124/76, HR 72 regular, RR 16, SpO2 98% room air, Temp 37.1°C. • Surgical Site: Lower midline abdominal incision is clean, dry, and intact with staples. No erythema or active bleeding. Minimal serous drainage on 4x4 gauze. • GI/GU: Abdomen soft, moderately tender around incision, active bowel sounds in all 4 quadrants. Passed flatus this afternoon. Tolerating clear liquids. Voided spontaneously 350 mL clear yellow urine at 16:30. • Mobility: Ambulating in hallway with physical therapy and 1-person assist.
R

Recommendation / Request

Specific clinical action needed, timeframe & read-back confirmation

• Advance diet to soft regular diet tomorrow morning as tolerated. • Evening dose of IV Acetaminophen due at 22:00. • Encourage incentive spirometry (10 breaths/hour while awake). • Morning BMP and CBC ordered for 05:00 to verify stable renal function. • Plan for discharge teaching if ambulation and oral intake continue to advance.
Looking for more worked handoff examples and clinical case studies?Explore Shift-to-Shift Handoff Example on SBAR Examples →

5-Step Bedside Handoff Safety Protocol

According to The Joint Commission Sentinel Event Alert on handoff communications, conducting reports directly at the patient's bedside reduces medical errors by enabling joint physical verification:

1. Dual Patient Identification Check

Verify two unique patient identifiers (Full Name & DOB on the hospital wristband) with both outgoing and oncoming nurses present at bedside.

2. Physical Line & Infusion Tracing

Physically trace all IV tubing from infusion bags to pump channel rates and directly to the insertion site. Verify line patency and site dates.

3. Surgical Dressing & Drain Review

Uncover and visually inspect surgical incisions, wounds, and drain outputs (JP bulbs, chest tubes, ostomy appliances) together.

4. High-Alert Medications & Lab Review

Dual-sign active heparin, insulin, or PCA continuous infusions. Review pending morning blood draws and scheduled STAT diagnostics.

Departmental Transfer & PACU Handoff Guidelines

When transferring patients between departments (e.g. ED to ICU, PACU to Floor, or Med-Surg to Step-Down), the SBAR handoff must emphasize airway stability, anesthesia recovery scores (Aldrete score), fluid balance, and transport monitoring needs.