Incomplete record transfer at shift handover
At 19:10 a dietitian covering the evening receives a handover for a 60-year-old inpatient with a new diagnosis of type 2 diabetes and a stage 2 pressure injury. The handover note reads: 'Diet review done. Pt educated. F/U.' There is no record of the patient's weight, intake, wound status, cultural or religious dietary needs, or what was taught. The patient speaks limited English and the family has been bringing food from home. The ward nurse says the dietitian who wrote the note has left and cannot be reached. The patient is due for discharge in the morning.
1. How should the dietitian proceed with the assessment given the inadequate handover?
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Treat the note as insufficient to rely on and reassess rather than assume. The dietitian should review the medical record for weight trend, biochemistry, wound staging and intake charts; if absent, obtain and document them. Then see the patient with a qualified interpreter to establish actual intake, what foods the family brings, and whether the previous education was understood - 'educated' in a note does not establish that learning occurred.
The cultural and religious dimension is clinically relevant, not a courtesy: the family's home food may be appropriate or may be undermining glycaemic and wound-healing goals, and the plan must work with it rather than around it. Document the assessment findings, the plan, and the education given with teach-back evidence before discharge.
2. What should be documented and what should be raised about the handover practice?
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Document a complete entry: anthropometry, intake, wound-relevant nutrition status, the interpreter used, the patient's and family's food practices, the education delivered and how understanding was confirmed, and a clear follow-up plan with who is responsible and when. A note that another clinician can act on is the standard - 'F/U' with no content fails it.
Raise the handover quality issue through the line manager or clinical governance: a handover that omits weight, intake, wound status and education content is not a handover. The service should agree a minimum dataset for dietetic handover and audit it. Because discharge is imminent, the dietitian should also ensure the discharge summary and primary care referral carry the actual plan, so the information gap is not simply moved downstream.