Patient Handoff Report

Patient information
❏ Patient name: _______________________________
❏ Room #: ________ Wounds
❏ Age________ ❏ Location:_____________
❏ A & O Status________________ ❏ Size: L_____W________
❏ Vitals: BP____T___RR___02_____HR____ ❏ Dressing:_____________
❏ Past Medical HX____________________________ ❏ Undermining:__y___N
_______________________________________________ ❏ Tunneling:___Y____N
❏ Admitting DX:______________________________ ❏ Drainage: ____________
❏ Allergies: __________________________ ❏ Odor:______________
❏ Code Status: Full__ DNR__
❏ Glasses: Y__ N___
❏ Dentures: Y__ N__
❏ Diabetic: Y___ N__ Last Glucose level_________
❏ Diet: ______________ Tube Feeding
❏ Type of tube:__________________
❏ Formula:_____________________
IV / PICC/ MIDLINE ❏ Rate:________________________
❏ Location____________ ❏ Pleasure Feeds: Y___ N___
❏ Indication:______ ❏ Site condition_________________
❏ Gauge:_________ ❏ Dressing Condition_____________
❏ Fluids__________
❏ Antibiotic______
❏ Condition of site_________ Ambulation/ADL
❏ Condition of dressing_________
❏ Walking__________
❏ Transferring________
Oxygen Delivery ❏ Hygeine___________
❏ Room Air___%___amount ❏ Bathing___________
❏ Nasal Cannula _____%____amount
❏ Mask _____%_____amount
❏ Trach_____%_____amount
❏ Vent____Tidal____Fio2___peep___setting___RR
Labs/ Diagnostics
❏ BMP:______________
❏ CBC :_____________
Elimination ❏ Creatinine :__________
❏ Continent: Bladder___Bowel__ ❏ Cardiac Enzymes :__________
❏ Incontinent :Bladder___Bowel___how long________ ❏ Trough Levels:_____________
❏ Foley:__Y__N___size ❏ EKG:___________
❏ Last Void:______color____clarity_____ ❏ X RAY:____________
❏ Dysuria: ____Y_____N____ ❏ CT/MRI:___________
❏ Last BM:_______

Last Meds Given

Precautions & Reason ❏ Antibiotics :_______Next due______
❏ Contact :________
❏ Pain: ________Next due______
❏ Droplet :________
❏ Antihypertensives: _______Next due______
❏ Airborne:_______

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ANGIE 2018