Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Recommendations

1.0 Assessment:

1.1 Assess the client’s current and evolving care requirements on admission, regularly throughout an episode of care, in response to a change in health status or care needs, at shift change and prior to discharge.
1.2 Obtain a “best possible medication history” during care transitions by using a structured and systematic process to collect client medication information that includes dose, frequency and route.
1.3 Assess the client for physical and psychological readiness for a care transition.
1.4 Assess the client, their family and caregivers for factors known to affect the ability to learn self-care strategies before, during and after a transition.
1.5 Assess the learning and information needs of the client, their family and caregivers to self-manage care before, during and after a transition.

2.0 Planning:

2.1 Collaborate with the client, their family and caregivers and the interprofessional team to develop a transition plan that supports the unique needs of the client while promoting safety and continuity of care.
2.2 Use effective communication to share client information among members of the interprofessional team during care transition planning.

3.0 Implementation:

3.1 Educate the client, their family and caregivers about the care transition during routine care, tailoring the information to their needs and stage of care.
3.2 Use standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions.
3.3 Obtain accurate and complete client medication information on care transition.
3.4 Coach the client on self-management strategies to promote belief in their ability to look after themselves on care transition.

4.0 Evaluation:

4.1 Evaluate the effectiveness of transition planning on the client, their family and caregivers before, during and after a transition.
4.2 Evaluate the effectiveness of transition planning on the continuity of care.
4.3 Evaluate the effectiveness of communication and information exchange between the client, their family and caregivers and the health-care team during care transitions.