patients information all updated in an electronic app for patient handover report by nurse

by Mohammad Schmitt 7 min read

Nursing Handover using an Electronic Application for …

4 hours ago Failure of effective handover is a major preventable cause of patient harm. We aimed to promote accurate recording of high-quality clinical information using an Electronic Handover System (EHS) that would contribute to a sustainable improvement in effective patient care and safety. Within our hospit … >> Go To The Portal


What is the patient handover?

Patient handover from one unite to another represents a vulnerable time for communication errors that result in the loss of clinical information Optimizing the patient handoff between emergency medical services and the emergency department

How was the Electronic Clinical handover template designed?

An electronic clinical handover template was designed based on the ISBAR3 clinical handover tool (health.gov.ie/wp-content/uploads/2015/01/ISBAR3-Shift-Clinical-Handover-Nov2014.pdf) using Microsoft Word. A Clinical handover protocol was produced in order to provide a guide for staff to handover patients.

What is the Preferred Reporting item for patient handover challenges?

A systematic review was conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-analyses guideline. The key words “challenges of patient handover” or “challenges of patient handoff” were used in combination with the Boolean operators OR and AND.

How many patients use both a computer and a smartphone Health app?

★ Among patient portal users who accessed their portal 6 or more times in 2020, 45 percent used both a computer and a smartphone health app compared to 22 percent who used only a computer and 28 percent who used only a smartphone health app.

Why is patient handover important?

Why is failure of effective handover important?

About this website

Why is it important to update patient information?

The maintenance of good medical records ensures that a patient's assessed needs are met comprehensively. Information in medical records should be documented on a daily basis and in chronological order demonstrating continuity of care and response to treatment.

What is electronic nursing documentation?

Electronic documentation includes such skills as electronic data entry and data extraction for preparing care plans, planning patient care and education, and discharge planning; it is rapidly becoming a major practice competency.

What does documentation of clinical handover contain?

Acceptance of responsibility for the care of the patient by the clinician receiving handover. Document findings and include changes in clinical condition and feedback from patient/ family/ carer regarding ongoing care requirements; update management/care plans.

How do you hand over a nursing report?

Here are five tips to polish your handover technique:Be organised. Try to follow an organised sequence when handing over: patient details, presenting complaint, significant history, treatment and plan of care. ... Stay focused. Stay relevant. ... Communicate clearly. Be concise and speak clearly. ... Be patient-centred. ... Allow time.

How do nurses use electronic health records?

Electronic health records are mainly used by nurses to get medication reminders, prevent drug interactions, gain immediate access to patient medical history, and documentation of clinical care.

Why is electronic documentation important in nursing?

Electronic health records (EHRs) support that documentation with data that help you enhance patient safety, evaluate care quality, maximize efficiency, and measure staffing needs. And they serve as a standard form of documentation that can be shared by everyone on the healthcare team.

What information would you give when completing a handover and why?

5 tips for a better patient handoverPast: historical info. The patient's diagnosis, anything the team needs to know about them and their treatment plan. ... Present: current presentation. How the patient has been this shift and any changes to their treatment plan. ... Future: what is still to be done.

What are the different types of documentation that may be used during a handover?

Handover requires preparation to ensure the effectiveness and efficiency of the process. Support workers should obtain and update necessary documents, including shift reports, the communication books, and the diary. Other relevant documentation might include incident reports and any other forms, charts or plans.

How do you conduct effective handover in nursing and patient care?

Everyone listening to the handover must understand the information you share, which means you need their full attention. Take ownership of your handover: ensure that people don't have conversations amongst themselves while you speak. Furthermore, you should prevent people from continuously interrupting with questions.

Why are nursing handovers important?

An accurate handover of clinical information is of great importance to continuity and safety of care. If clinically relevant information is not shared accurately and in a timely manner it may lead to adverse events, delays in treatment and diagnosis, inappropriate treatment and omission of care.

What should be included in a nursing report?

It should include the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.

What is the purpose of a nursing handover?

Handover is a crucial part of patient care to ensure continuity and to provide the best possible and safe care to patients. However, as times change and service demands increase, it is easy for this process to become rushed or to lose sight of who should be involved.

What is the best nursing handover style to ensure continuity of ...

An accurate handover of clinical information is of great importance to continuity and safety of care. If clinically relevant information is not shared accurately and in a timely manner it may lead to adverse events, delays in treatment and diagnosis, inappropriate treatment and omission of care.

G009 nursing handover for adult patients guidelines

NURSING HANDOVER FOR ADULT PATIENTS GUIDELINES Date validated: May 07 Date operational: June 07 Date to be reviewed: June 08 Page 3 of 13 • A safety briefing (please see appendix 1) is undertaken at the beginning of a shift handover.

Guidance on clinical handover for clinicians and managers

Safe handover: safe patients 3 Effective communication lies at the very heart of good patient care. The General Medical Council recognises this and in its publication Good medical practicemakes clear the expectation that doctors will ‘keep colleagues well informed when sharing the care of patients’.

Chapter 32 Structured patient handovers - NICE

Emergency and acute medical care Chapter 32 Structured patient handovers 5 32 Structured patient handovers 32.1 Introduction Handover is the system by which the responsibility for immediate and ongoing care is transferred

The research

At The University of Texas Medical Branch, a Magnet®-recognized facility, we used our evidence-based practice (EBP) model, called Disciplined Clinical Inquiry, to uncover and translate the best evidence in our practice setting. We formed a team composed of a clinical expert, nurse manager, and bedside clinicians.

The test

Based on the integration of the best available evidence, we designed a 3-month rapid cycle system prototype using web-enabled technology to improve patient and nurse satisfaction during cross-unit transfer of care from one nurse to another.

The evaluation

We evaluated our initiative using a presdischarge patient opinion survey, focusing on the patient’s experience during the virtual handoff.

The challenges

The virtual handoff introduced change into the nurses’ routines, so we encountered some resistance. Although only a few admitted it during the planning phase, some nurses claimed lack of competence using the tablets to make video calls.

The final analysis

On the whole, we received positive feedback from patients and nurses. The active engagement of our nurse manager facilitated coverage of the technology cost and helped sustain nurse participation in practice change, a key element in Magnet recognition.

Selected references

Gregory S, Tan D, Tilrico M, Edwardson N, Gamm L. Bedside shift reports: What does the evidence say? J Nurs Adm. 2014;44 (10):541-5.

What is clinical handover?

Clinical handover: defining the problem#N#Clinical handover is defined as inter-clinician communication occurring at care interfaces. This usually refers to changes of shift within a clinical team. In essence, clinical handover is the transfer of professional responsibility and account- ability for some or all aspects of a patient’s care to another person or professional group on a temporary or permanent basis (British Medical Association 2004; Royal College of Physicians 2011). With the decrease in hours worked in modern medical practice, the number of handovers performed has increased proportionally. This has raised concerns about continuity of care and the potential for patient safety to be compromised. Indeed, clinical handover has been identified as a major preventable cause of harm (Royal College of Physicians 2011; Who 2007). In root cause analyses of sentinel events, communication is repeatedly identified as an area of concern. In almost 66 percent of cases, communication is identified as the root cause, or a key cause of the adverse event (Joint Commission 2007). Ineffective clinical handover has been shown to increase the risk of preventable adverse events, length of stay and rate of complications.

What is electronic handover?

An electronic clinical handover project was piloted within our medical department. the pilot concept and protocol was discussed and agreed upon by the Medical Department, General Manager and Clinical Director. All staff were informed of the clinical handover pilot by email and at a departmental meeting. In addition, in order to achieve ‘buy in’ a talk was delivered to all medical department doctors on the evidence base for clinical handover in the healthcare setting and the proposed clinical handover pilot.

Why is patient handover important?

BACKGROUND: The patient handover process is in fact a valuable and essential part of the care processes in the hospitals. This can be a factor in increasing the quality and effectiveness of medical care. Incorrect and incomplete handover can increase the percentage of errors and cause serious problems for patients.

Why is failure of effective handover important?

Failure of effective handover is a major preventable cause of patient harm, which is also the most important step in ensuring the patient's safe handover. Patient handover is in fact a valuable affair and an essential part of processes and workflows in hospitals.[3,4,5] In other words, one of the most important steps in ensuring the continuity ...

What is AI in urgent care?

Rather than waiting a couple hours just to start being seen by the nurse, the patient sits at a kiosk and interacts with an artificial intelligence (AI) assistant that asks the patient some questions tailored to the signs and symptoms.

Do external vendors use FHIR?

Many major vendors have app-type stores that these external vendors are working with to achieve interoperability. These stores may use FHIR interfaces, but proprietary EMR APIs still appear to be more prominent. Another potential channel that external apps are interested in using are the nationwide services.

Summary

Individuals’ rates of being offered and subsequently accessing their patient portal increased significantly between 2018 and 2019, but did not change in 2020.

Data Source and Methods

Data are from the National Cancer Institute’s (NCI) Health Information National Trends Survey (HINTS).

Suggested Citation

Johnson C, Richwine C, & Patel V. (September 2021). Individuals’ Access and Use of Patient Portals and Smartphone Health Apps, 2020. ONC Data Brief, no.57. Office of the National Coordinator for Health Information Technology: Washington DC.

What is ISHAPED EHR?

As appropriate, the ISHAPED tool pulls patient information into the designated ISHAPED section or hyperlinks to the area in the EHR. Displaying only pertinent items reduces the time needed for staff to process and communicate information. ISHAPED is designed to serve as an information repository rather than a documentation tool. As a result, the corresponding handoff process requires that all other nursing documentation in the EHR must be completed before the handoff report.

How many medical errors are the result of ineffective handoff communication?

According to Wheeler, approximately 70% of serious medical errors are the result of ineffective handoff communication. Handoffs completed at the patient’s bedside—which allow for direct patient visualization and communication between caregivers—improve the process.

What is Nebraska Medicine handoff process?

Nebraska Medicine created a project team to produce a standardized handoff tool and process . The team consisted of leadership from nursing professional practice and development, enterprise applications (electronic health record [EHR] analysts), clinical effectiveness, and clinical decision support. The team started by working to understand the negative issues related to the current handoff process. The inpatient oncology and hematology specialty care unit expressed an interest in working to improve its handoff process, so the project team engaged unit leadership and staff to help during the initial phase of the project, identifying gaps in information and processes.

What is handoff communication?

Handoff is a real-time process that involves the transfer of essential patient data from one caregiver to another.

What are the effects of ineffective handoff communication?

In addition to adverse events, ineffective handoff communication also has contributed to prolonged lengths of stay, avoidable readmissions, delayed or inappropriate treatment, increased costs, inefficiencies related to rework, and care omissions. Consequently, both agencies have emphasized improving and standardizing handoff communication.

Is handoff communication a high risk activity?

Handoff communication remains a high-risk activity . Translating processes from other safety methods, such as medication administration, to the handoff communication process will lead to more effective and safer handoff practices. Handoff should be completed separately from other nursing actions and

What is failure of effective handover?

Failure of effective handover is a major preventable cause of patient harm. We aimed to promote accurate recording of high-quality clinical information using an Electronic Handover System (EHS) that would contribute to a sustainable improvement in effective patient care and safety. Within our hospital the human factors associated with poor communication were compromising patient care and unnecessarily increasing the workload of staff due to the poor quality of handovers. Only half of handovers were understood by the doctors expected to complete them, and more than half of our medical staff felt it posed a risk to patient safety. We created a standardised proforma for handovers that contained specific sub-headings, re-classified patient risk assessments, and aided escalation of care by adding prompts for verbal handover. Sources of miscommunication were removed, accountability for handovers provided, and tasks were re-organised to reduce the workload of staff. Long-term, three-month data showed that each sub-heading achieved at least 80% compliance (an average improvement of approximately 40% for the overall quality of handovers). This translated into 91% of handovers being subjectively clear to junior doctors. 87% of medical staff felt we had reduced a risk to patient safety and 80% felt it increased continuity of care. Without guidance, doctors omit key information required for effective handover. All organisations should consider implementing an electronic handover system as a viable, sustainable and safe solution to handover of care that allows patient safety to remain at the heart of the NHS.

What is the Health Informatics Unit?

Health Informatics Unit, Clinical Standards Department, Royal College of Physicians. A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital.

Why is patient handover important?

BACKGROUND: The patient handover process is in fact a valuable and essential part of the care processes in the hospitals. This can be a factor in increasing the quality and effectiveness of medical care. Incorrect and incomplete handover can increase the percentage of errors and cause serious problems for patients.

Why is failure of effective handover important?

Failure of effective handover is a major preventable cause of patient harm, which is also the most important step in ensuring the patient's safe handover. Patient handover is in fact a valuable affair and an essential part of processes and workflows in hospitals.[3,4,5] In other words, one of the most important steps in ensuring the continuity ...

The Research

The Test

  • Based on the integration of the best available evidence, we designed a 3-month rapid cycle system prototype using web-enabled technology to improve patient and nurse satisfaction during cross-unit transfer of care from one nurse to another. Our Information Services Department configured two WiFi-enabled tablets and installed a secure, HIPAA-complia...
See more on myamericannurse.com

The Evaluation

  • We evaluated our initiative using a presdischarge patient opinion survey, focusing on the patient’s experience during the virtual handoff. Fifty percent of the patients (n = 10) who responded to the survey reported that the virtual interaction reduced their level of anxietyabout the transfer to a new care environment, 70% indicated that the virtual interaction with the nurse felt like real face-to-fa…
See more on myamericannurse.com

The Challenges

  • The virtual handoff introduced change into the nurses’ routines, so we encountered some resistance. Although only a few admitted it during the planning phase, some nurses claimed lack of competence using the tablets to make video calls. During the early part of the initiative, we also encountered problems with the WiFi connection and technical difficulties with the tablets thems…
See more on myamericannurse.com

The Final Analysis

  • On the whole, we received positive feedback from patients and nurses. The active engagement of our nurse manager facilitated coverage of the technology cost and helped sustain nurse participation in practice change, a key element in Magnet recognition. As a result of our EBP-disciplined clinical inquiry initiative, our intermediate specialty care unit and the surgical intensiv…
See more on myamericannurse.com

Selected References

  • Gregory S, Tan D, Tilrico M, Edwardson N, Gamm L. Bedside shift reports: What does the evidence say? J Nurs Adm. 2014;44(10):541-5. Jeffs L, Acott A, Simpson E, et al. The value of bedside shift reporting enhancing nurse surveillance, accountability, and patient safety. J Nurs Care Qual. 2013;28(3):226-32. Ofori-Atta J, Binienda M, Chalupka S. Bedside shift report: Implications for sa…
See more on myamericannurse.com