Institution
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Arkansas Children's Hospital Boston Medical Center Brigham and Women's Hospital Children's Hospital of Michigan Hurley Medical Center Intermountain Medical Center Levine Children's Hospital at Carolinas HealthCare System Maimonides Medical Center Mayo Clinic New York Hospital Queens Sunnybrook Hospital Trident Medical Center University of California Medical Center University of Cincinnati University of Hawaii John A Burn School of Medicine Virginia Commonwealth University Hospital Children's Hospital of Philadelphia New Hanover Lankenau Medical Center Children's Hospital Montefiore Children's Hospital Colorado University of New Mexico Hackensack UMC Mountainside Medical University of South Carolina Sparrow Hospital Johns Hopkins Baltimore Children's National DC Toledo Children's Hospital AtlantiCare Regional Medical Center Sanford Children's Hospital Gwinnett Medical Center Children's Mercy Kansas City Boston Children's Hospital North Shore Hospital Mount Auburn Hospital Bryn Mawr Hospital Beth Israel Deaconess Hospital-Milton
Date of observation
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Today M-D-Y
Observation Start
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Now H:M Please enter military time
Observation End
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Now H:M Please enter military time
Specialty
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Pediatrics Medicine Surgery Other
Specialty
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Medicine Surgery Other
Other
* must provide value
Other
* must provide value
Specific Service/Unit Name
* must provide value
Purple Team Blue Team
Specific Service/Unit Name
* must provide value
MICU
Specific Service/Unit Name
* must provide value
General Medicine
Specific Service/Unit Name
* must provide value
CHAM 6
Specific Service/Unit Name
* must provide value
4W CSH 7W MHT
Specific Service/Unit Name
* must provide value
Green Team Purple Team Teal Team Red Team
Specific Service/Unit Name
* must provide value
Academic Team
Specific Service/Unit Name
* must provide value
IPS
Specific Service/Unit Name
* must provide value
5E 5W Hybrid
Specific Service/Unit Name
* must provide value
Neill Zinkham 10S
Specific Service/Unit Name
* must provide value
Gen Peds Inpatient Hospitalist
Specific Service/Unit Name
* must provide value
FIRM
Specific Service/Unit Name
* must provide value
Team 1 Team 2 Team 3 Team 4 Team 5 Team 6 Team 7 Team 8 Night Float
Specific Service /Unit Name
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Type of service
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ICU General inpatient ward Specialty inpatient ward Other
Other
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Provider/Resident SHM.I-PASS ID number
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Post graduate year 1 (PGY1) PGY2 PGY3 PGY4 PGY5 PGY6 PGY7 or more Other/ NA
Other/ NA, please specify:
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Champion/Faculty SHM.I-PASS ID number
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Attending Chief resident Senior resident other
RN PA Nurse Manager Hospitalist Attending, Other attending
Number of individual patient handoffs observed
How well do you know the patients whose handoff you are evaluating?
Very well Somewhat well Not at all
18. Indicate the phrase that BEST describes the pace of the handoff:
Very Slow pace/ Very inefficient
Slow pace/ Inefficient
Optimally paced/ Efficient
Fast/ Pressured pace
Very fast/ Very pressured pace
19. What was especially effective about the handoff?
20. What aspect(s) of the handoff could be improved?
0 1-2 3-4 5-6 >6
Charting Area Hallway Bedside Other
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