Free Nursing Handover Note Template
Nursing Handover Note
Prepared By: [YOUR NAME]
Date: April 18, 2050
A Nursing Handover Note is an essential communication tool in healthcare, enabling the transfer of patient information between nursing staff during shift changes or care transitions. By documenting key details about patient status and treatments, these notes promote continuity of care and enhance safety. Effective handover notes equip incoming nurses with crucial insights for informed decision-making, ultimately improving patient outcomes and healthcare efficiency.
I. Patient Identification
|
Name |
Jack Simmons |
|---|---|
|
Age |
45 |
|
Medical Record Number |
123456789 |
|
Diagnosis |
Acute Myocardial Infarction |
II. Current Status
|
Vital Signs |
|
|---|---|
|
Recent Lab Results |
|
|
Changes in Condition |
Patient reports reduction in chest pain. No symptoms of nausea or dyspnea observed in the past 24 hours. |
III. Care Needs
|
Medication Administration |
|
|---|---|
|
Treatments Required |
|
|
Special Considerations |
Monitor for signs of bleeding due to anticoagulant therapy. Encourage patient to report any unusual bruising or bleeding. |
IV. Safety Issues
|
Allergies |
|
|---|---|
|
Fall Risks |
High fall risk. Ensure bed rails are up and call bell is within reach. |
|
Other Concerns |
Patient has history of hypertension, requiring close monitoring. |
V. Pending Tasks
|
Scheduled Tests |
Echocardiogram scheduled for tomorrow at 10:00 AM. |
|---|---|
|
Follow-Up Appointments |
Cardiology follow-up appointment scheduled for one week post-discharge. |
|
Additional Care Activities |
Complete discharge planning notes and coordinate with social services for post-discharge support. |
