Template: Observation and reporting to colleague
Get the important parts in so the next person can act correctly
Good handover is patient safety. When you observe a change, those next in the chain must be able to understand it without guessing. Use a fixed structure so nothing important falls out.
§What you observe
- 01What did you actually hear or measure? (facts, not interpretation)
- 02When did it occur and how long has it been going on?
- 03Is it a change from the person's normal condition?
§What you did and recommend
- 01What did you do yourself in response?
- 02Who have you contacted – nurse, doctor, relatives?
- 03What should the next one be particularly careful about?
Write the same in the documentation as you say verbally. What is written in the journal is what is actually passed on when you have gone home.