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Multiple Patient Peer Assessment Form
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Multiple Patient Peer Assessment Form
Multiple Patient Peer Assessment Form
rlandrigan
2026-03-31T14:40:43+00:00
Multiple Patient Peer Assessment
Hospital or Location
(Required)
Ephraim McDowell Regional Medical Center
Ephraim McDowell James B Haggin
Ephraim McDowell Fort Logan Hospital
Unit or Service
(Required)
ICU
PCU
Emergency Room
CVU
3T
5T
6T
Behavioral Health
LD/NUR
OR
Cath Lab/IR
1 East
Respiratory Therapy
Acute/Med/Surg/Swing (Fort Logan)
Recovery Services
Provider Type of Individual GIVING Handoff
(Required)
Respiratory Therapist
Provider Type of Individual RECEIVING Handoff
(Required)
Respiratory Therapist
Day of Week
(Required)
Weekday
Weekend
Time of Day
(Required)
AM
PM
How many interruptions occurred during the observed handoff session?
(Required)
0
1 to 3
More than 3
Peer Handoff Assessment
The Receiver should assess the presence and quality of the I-PASS mnemonic elements (I, P, A, S) and the Giver should assess the presence and quality of the synthesis. Use the same assessment form for both parts of the assessment.
Indicate whether or not each element of the mnemonic is present
(Required)
Never
Rarely
Sometimes
Usually
Always
I. Illness Severity (Receiver to assess)
P. Patient Summary (Receiver to assess)
A. Action List (Receiver to assess)
S. Situation Awareness/Contingency Planning (Receiver to assess)
S. Synthesis by Receiver (Giver to assess)
I. Illness Severity: Identification as stable, "watcher", or unstable; must occur at the beginning of each patient handoff. P. Patient Summary: Might include summary statement, events leading up to admission, hospital course, ongoing assessment, plan. A. Action list: To do list; (must be separated from patient summary). S. Situation Awareness & Contingency Planning: Review potential problems with recommended action or identify as a pertinent negative. S. Synthesis by Receiver: Brief high-level repeat back of key summary, action, and contingencies
Indicate whether or not the following elements were present in the observed handoff:
(Required)
Never
Rarely
Sometimes
Usually
Always
Giver actively engaged with receiver to ensure understanding of patients (Receiver to assess)
Giver appropriately prioritized key information, concerns, or actions (Receiver to assess)
Provided to-do list restricted to items that need to be accomplished on next shift (Receiver to assess)
Used high quality contingency plans with clear if/then format (Receiver to assess)
Receiver provided a synthesis that summarized the key components of the handoff, rather than restating all information (Giver to assess)
(Receiver to answer) Was an I-PASS Written Handoff Tool used to facilitate the verbal handoff process?
(Required)
Yes
No
(Receiver to answer) How would you rate the overall quality of the written handoff tool?
(Required)
Excellent - The tool is clear, concise, up to date, and highly useful for ensuring safe and effective handoffs
Good - The tool is generally clear, complete, and up to date, with minor areas for improvement
Fair - The tool has notable gaps or ambiguities that could impact safe and effective handoffs
Poor - The tool is unclear, incomplete, or lacks critical information needed for safe and effective handoffs
Not applicable - A written tool was not reviewed
Share one REINFORCING piece of feedback based on your handoff observation (Giver and/or Receiver to answer)
Share one CORRECTIVE piece of feedback based on your handoff observation (Giver and/or Receiver to answer)
Survey Respondent (GIVER)
(Required)
First
Last
Survey Respondent (RECEIVER)
(Required)
First
Last
