Written by Dr. Chenghao Qian (May 2021)

Those Giving Sign Out:

1. Update that patient summary: a concise yet comprehensive, UPTODATE one liner is paramount to a good sign out. Emphasis on CONCISE (especially for stable patients), as night float has 80+ patients. Please don't recite a patient's whole story and hospital course if it is not relevant information for overnight emergencies!
2. Leave little to interpretation: you know your patient the best, so make that contingency plan. What are you most worried about? Write it down (IF → THEN)
3. Wrap up your patient: F/U labs, sleep aid, PRN Tylenol, bowel regimen, restraints, and consent forms. Take care of these before you leave.
4. Write it down, write it down: NF will not remember that one last FYI thing you just remembered in the middle of signing out. If you think it's important, write it down.

Those Getting Sign Out:

1. Ask Ask Ask: "Okay so what do you want me to do if this happens?" "Can you clarify this part of the sign out?" "Are the labs ordered? Do I need to follow up on this?" "Sounds like pt is sick, what should I look out for if he decompensates?" "Okay just to clarify, XXX is what I should do if patient develops XXX symptoms?"
2. Give feedback the next day: "Hey I noticed that f/u lab was not ordered so I ordered it for you." "Hey that UGIB patient was not consented for blood."
   What to write in sign out?
   I-PASS handoff model
   Illness severity status - usually only need to note sick patient
   Patient data - solid one-liner, FYIs
   Action Plans - to dos with follow up plan
   Situation awareness/contingency plans - if → then.
   Synthesis by receiver - clarify everything by NF.

General Structure:

Patient summary: xx yoM/F h/o pertinent PMH presents with sx concerning for xxx with current clinical trajectory.

FYI: Something NF should know and what they should do if something bad happens (ex: patient aspirated 2x days ago, if fever/clinically decompensate, treat for HAP)

To Dos: If you want NF to follow up on a lab, write what you want them to do (ex: MN lytes, replete K>4, Mg>2)

Fluid: How should NF give fluid if needed? 1L bolus? 500cc? 250cc? no fluid at all?
Pain: what’s onboard? What should NF give if pt has pain? Are you okay with opioid?
Sleep: Melatonin onboard? Can NF do trazodone? What about benzos?
Abx: What the current abx onboard? If patient gets worse, what else to give?
Baseline: pertinent baseline exam only (many times it’s mental status or neuro)
Capacity: if no capacity, who should NF call? Put name and number here.
Code: Full? DNR? Okay for intubation?

Bad Example:

Patient summary: 65 yoM h/o HTN, DM, BPH, depression, CHF here for heart failure exacerbation getting diuresed.

Sign out:

NTD/CIS
FYI: BP soft
[ ] MN lyte check
Fluid: per NF
Pain: per NF
Sleep: per NF
Abx: none
Baseline: on RA, bibasilar crackles, 2+ pitting edema, JVP to jaw.
Capacity: yes
Code: FULL

What’s wrong?

• Lack of pertinent information on patient summary. Is the patient diuresing well? Any complications? Is he improving? Non-pertinent PMH clutters the one liner. Do you need depression in the summary? Is it active?
• FYI lacks information. Why is BP soft? What should NF do if it gets worse?
• NTD/CIS should only be written when you mean it. NO anticipatory action for NF and culture if patient spikes (in this case, NF asked to check MN labs but still wrote NTD)
• ”Per NF” is lazy. NF is not the primary team. Write contingency plans or guidance.

Improved Version:

65 yoM h/o controlled HTN, T2DM, HFrEF (EF 20%) presents with acute SOB found to have HF exacerbation currently diuresing well non-dyspneic on RA however still hypervolemic on exam.

CIS
FYI: UOP 3L today, BP soft. Consider 250cc bolus if BP worsens
[ ] MN lyte check, K>4, Mg>2
Fluid: EF 20%, 250cc bolus
Pain: Tylenol, lidocaine patch, can give norco 5mg x1
Sleep: Melatonin
Abx: none
Baseline: on RA, bibasilar crackles, 2+ pitting edema, JVP to jaw.
Capacity: yes
CODE: FULL