Handover patient clinical documentation, letters of referral and

Handover of care is one of the most perilousresponsibilities of a nurse, and failure to carry it out properly can be amajor contributory factor to subsequent error and harm. Inadequatehandover of clinical information carries significant risks not only for thehealthcare team, for the organisations involved, but most importantly for the patients.A good handover is at the heart of an e?ective health care system and standsalongside patient clinical documentation, letters of referral and transfer anddischarge documentation.

Together, these make up the links in the chain ofcontinuity of patient care.  Handoverrequires systemic and individual attention and needs education, support,facilitation and sustained e?ort to ensure it maintains a position ofimportance in an already full working day. The changing patterns of the nurses’ workhave created a need to improve handover across all settings.

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Ensuring effectivetransfer of responsibility and information is a vital component of a goodpatient care. Thus, there is a growing need to enhance handover tools andsystems in order to maintain high standards of patient care. In response to this, electronic handover toolsemerged which are now utilized in various healthcare settings. They have becomean integral part of the institutions’ frameworks and policies.

The abovestudies revealed that this modern technological advancement has improvedcontinuity of care, reduced adverse patient events, enhanced flow ofinformation, and reduced time for handover. Nurses, who directly provide careto patients, are therefore required to ensure that they have a fullunderstanding of the tool as a basis for safe handover. Familiarity of how thesystem works is paramount to the delivery of quality and effective care. Whileit is therefore true that technologyhas penetrated a number of healthcare institutions and has resulted to somemajor improvements, nurses must still keep in mind that decisions to implement thesetools must be carefully observed. They must base the implementation on demonstrable safety benefits orother advantages to clinical practice. They must ensure that all criticalinformation is communicated properly because only through a complete andcomprehensive handover will they establish basis for the next course of actionfor continuity of care.

On the other hand, standardisationof handover also plays a vital key to improvements in efficiency. Awell-structured report enables nurses to have a complete grasp of allinformation needed for the patients’ continuity of care. Since continuity ofinformation is crucial to the safety of every patient, a detailed handover ofclinical information is more important than ever. Sufficient and relevantinformation should be exchanged to ensure patient safety because the continuityof information underlies the continuity of care. To ensureeffective continuity of information, the handover must achieve a balancebetween comprehensiveness and efficiency. Thus, an understanding of the conceptof the system and personal continuity should be supported by education andtraining. Nurses must take relevant efforts to develop a sense ofresponsibility to educate and train themselves to further their knowledge andto establish measures to support the delivery of safe and quality care.

Inconclusion, an electronic and standardised handover tool should not take theform of a stand-alone initiative. It should form part of an overarching,trust-wide policy of team working, based on appropriate and effective sharingand use of patient care information. Nurses must ensure that the underlyingstructures and processes are in place and that each one of them is totallysupported in achieving effective handover. Nurses must communicate informationeffectively and help in the development of measures to improve clinicalhandover.

They must establish partnership and support informaticists  in developing tools that reflect the fullspectrum of evidenced-based and standards-based nursing practice. Moreover,nurses must position themselves to exert greater influence in thetransformation of healthcare for the benefit of all because nurses are goodstrategists, problem-solvers and decision-makers.