Documentation required for handover must contain accurate patient information. This must include a list of patients being discussed. Inpatient charts should include content details as described below: Outpatient documentation may include verbal or written communication between the resident and attending physician or another resident. The content should also follow the outline below.
Ability to update document at any time by house staff at all levels
Content (ISBAR)
I : Identifying data
Patient name and/or medicare or hospital ID number Room #, or telephone number
Admitting diagnosis or presenting complaint
Code and intubation status if appropriate
S : Situation
Clinical status – stable or clinical change
B : Background
Clinical course since admission or since last outpatient assessment Co-morbidities
Medications
A : Assessment
Current clinical assessment Stable or working diagnoses
R : Response
Recent / current investigations and management
Results of recent / current investigations and management
Plan / recommendations for upcoming investigation and management