The Nurse's Referral Handover Checklist

All nurses have had a poor handover and most can describe the emotion of a poor handover, one of not knowing what they are responsible for. Now look at the handover most support arrangements start from.

When a patient is discharged or referred to a community setting, a worker begins to support the patient, and what goes along with the patient is often a diagnosis, an address and goodwill. What the worker really needs, what the mornings must be like, what the risks are, what to look for, who to call, all come slowly through trial or error, or they don't come at all. This is not an acceptable standard for a nurse to set for themselves from shift to shift. It should not be accepted at the clinical care and daily support margin, which is the margin where patients spend their time.

The solution is a one-page discipline: a referral handover created by the nurse who knows the patient, understandable by a worker who has no clinical training, and delivered before the first shift. This is the information you need to put on the page.

The checklist

The person, before the patient. Who they are: how they can be called, what they like, how they communicate, what they want a good visit to look like from their perspective. Workers meet a person and so should the handover.

The practical picture. Support required, when, routines, which ones work and which don't, mobility and transfer needs in doing-language, equipment in use, and support in the household; who else is home, pets, access.

The safety essentials. Allergies. Where appropriate, swallowing or eating needs or requirements at the level at which a worker must work safely, with a pointer to any formal plan. Falls risk and factors that decrease falls risk. Medications mentioned in the worker's actual medication role: prompting from a webster pack or no medication role. Anything the worker must never do, with the one-line reason.

The watch list. As discussed earlier in this series, three to four changes that are important for this patient, in plain observational language.

The escalation line. The numbers that answer, the people to call, urgent-today and routine, the after-hours answer, so deterioration does not keep office hours.

Consent and privacy scope. The information shared with the support team is what the patient agrees to, and is recorded to help the worker understand what they would like shared and what they would not.

What stays off the page

The handover is a support document and not a medical record being transferred. The clinical detail is only valid if it alters the action of the worker; history, results and diagnostic nuance without any change to the action remain in the clinical record where they belong. This is both a matter of privacy law and usability, and a page that a worker reads in the car trumps a file that nobody reads, every time.

Making it stick as practice

The checklist is effective if it ceases to be an act of individual conscientiousness, and becomes a standard artefact of every worker who works with the referral: the checklist is a template in the system, each patient has a named author, the checklist is triggered when the clinical picture changes, and the checklist is copied to each new worker who comes into the system, including the fill and bench workers who are most likely to be new. Updates, one 10 minute visit per patient. Compare this expense to what the lack is currently costing: first shifts are based on guesswork, risks are only found when they happen, and the capacity to observe is wasted when there is no one to tell the observer about the risks.

How this plays out in practice

Imagine two employees who began at the same time on the same week with similar patients. The first one is assigned an address and "assistance with personal care and meals." Her first fortnight: the transfer technique by trial, swallowing requirement found when a family member gets in the way at mid-meal, GP number called twice.

The second gets the one page handover and provides an informed, safe, personal shift from the first morning, and on day 6 flags drinking reduction from the watch list two days earlier than it would otherwise have come up. Equal competence and goodwill. One page apart.

Next steps

Construct the template over the course of this week and then test it out on your next three referrals that go to support arrangements. Then ask the workers what the value of the page was. The solution to their problems is the business case.