Patient Handoff Communication Checklist Form
Complete this checklist to ensure safe and effective transfer of essential patient information between caregivers or teams.
Patient Name
*
First Name
Last Name
Date and Time of Handoff
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Primary Diagnosis
*
Current Condition Summary
*
Known Allergies
*
None
Drug Allergy
Food Allergy
Latex Allergy
Other
Current Medications
*
Pending Labs or Procedures
Infection/Isolation Precautions
*
None
Contact Precautions
Droplet Precautions
Airborne Precautions
Other
Code Status
*
Full Code
Do Not Resuscitate (DNR)
Do Not Intubate (DNI)
Other
Handoff Completed By (Name and Role)
*
Submit
Should be Empty: