ShiftIQ  ·  Shift Handoff Intelligence  ·  Concept prototype — Sarah Brock, NHA  ·  Fictional patient data throughout
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ShiftIQ
SHIFT HANDOFF INTELLIGENCE
Sunrise SNF  ·  2-North Wing
DAY SHIFT  ·  7:00 AM
Handoff from T. Martinez, RN (Night)
KR
K. Reynolds, RN
ShiftIQ
Shift Intelligence Platform
Clinical data transfers at shift change. Human knowledge doesn't.
Every shift, the most important things a nurse knows about a patient — the soft signals that change how care actually lands — disappear at handoff. ShiftIQ captures them and surfaces them to the next team before they walk into the room.
What gets captured
Pain Patterns — Mary says 4/10. Treat it as 7.
Family Dynamics — George's daughter hasn't visited in 6 days.
Behavioral Routines — Write your name on Bob's board. Every time.
Cognitive Triggers — Morning news orients George. Don't skip it.
What this prototype demonstrates
SBAR handoffs augmented with AI-detected soft intelligence from staff observations across multiple shifts
Role-specific views — RN sees clinical detail, CNA sees ADL needs and care tips — same patient, different lens
Verbal note capture with live transcription and automatic AI categorization into the four intelligence pillars
Five patients, five distinct clinical stories — from Day 1 new admits to Day 11 stroke recovery with expressive aphasia
Five patient profiles — each showing something different
CriticalPain uncontrolledDNR
Mary Johnson78F · Room 201A · Day 4
Mary says her pain is a 4. Her face says 7. Six shifts of documented evidence — and her DNR decision-maker daughter hasn't visited in 4 days. This profile shows what ShiftIQ does when the most important clinical signal lives in staff observations, not the chart.
Open
WatchCHF riskSundowning
George Williams84M · Room 203B · Day 7
When his daughter visits, George sticks to his fluid restriction. She hasn't come in 6 days — and his compliance is slipping. This profile shows how ShiftIQ connects family presence to clinical risk through staff-documented behavioral patterns.
Open
StablePT 10AMBG due
Ravi Patel71M · Room 205A · Day 2
Highly motivated post-op knee replacement, Day 2 — his granddaughter's birthday is his discharge goal. Shows how ShiftIQ builds a profile from scratch and surfaces personal motivation as a clinical tool from the very first shift.
Open
New admitO2 2L NCDay 1
Sarah Kim66F · Room 207B · Day 1
Day 1 COPD exacerbation admission — shows the new admit experience. ShiftIQ already captured two preferences from intake, and prompts staff with exactly what to ask this shift to start building her human profile.
Open
AphasiaINR due11 shifts of data
Bob Carter82M · Room 210A · Day 11
Bob cannot speak but understands everything. Eleven shifts of staff observations built the deepest intelligence profile on the floor — the whiteboard ritual, morning news anchor, wife Carol's visit pattern, and a full communication guide built entirely from behavioral documentation.
Open
Handoff Intelligence
Night → Day  ·  07:00 AM  ·  From T. Martinez, RN  ·  2 items need resolution before you start
5
Patients on floor
2
Unresolved items
8
AI-captured insights
3
Meds due by 9AM
Soft intelligence captured · 12 hours · Night shift
Pain Patterns Family Dynamics Behavioral Routines Cognitive Triggers
Pain Pattern
Mary minimizes her pain scores. When she says 4/10, treat it as 6–7. She grimaces and guards — watch behavioral cues alongside what she reports. Tylenol ES has been more effective than morphine, documented across 4 shifts.
6 entries · Night + Eve CNAs AI-verified pattern
Family Dynamics
Daughter Linda hasn't visited in 4 days — she normally comes daily around 2PM. Mary has asked about her twice this shift. Linda is the DNR decision-maker, so no procedure consent without her present. Flag social work if absence continues past Day 6.
AI flagged · CNA + RN notes Social work flag pending
Family Dynamics
Daughter hasn't visited in 6 days — he asks about her every morning. When family is present, fluid restriction compliance is measurably better, documented across 7 shifts. He was quieter than usual at 0200. Extra presence this morning matters.
AI flagged · CNA notes Mood decline correlation
Cognitive Triggers
Morning news orients him significantly better than verbal reminders or the clock. Turn it on when he wakes. Sundowning escalates after 6PM — calm, slow, simple communication works best then. He sometimes asks for his wife, who passed 2 years ago. Acknowledge warmly, redirect gently, never argue.
7 shifts of data Morning news: orient first
Behavioral Routine
His granddaughter's birthday next week is his stated discharge goal — he's mentioned it in every interaction since Day 1. Use it when framing PT and recovery conversations. He's also more cooperative for an hour after his wife's 8AM call, so time morning cares accordingly if you can.
Documented · Day 1 intake + all staff PT prep due 9:45 · 2-assist
Cognitive Triggers
He's a retired engineer — explain the clinical reasoning behind each intervention and compliance improves noticeably. "Your knee swells because..." works better than "we need you to elevate." He processes by understanding cause and sequence, and he engages meaningfully when you give him that context.
Patient self-report · Night staff confirmed
Behavioral Routine
She sleeps with two pillows at home and can't breathe lying flat — HOB 30–45° is a respiratory need, not a preference. She flagged this herself at admission. Also prefers tea over coffee in the morning. Day 1 is the best window to build her profile, so capture anything she mentions in every interaction.
Patient self-report · Night RN + CNA Profile building — Day 1
Family Dynamics
No family contact listed on admission — home support situation unknown. She may live alone. This is a critical gap for discharge planning. Ask her directly this shift about her primary contact and who will be available to help at home. Document in the chart today.
Gap flagged at admission Discharge planning · ask today
Behavioral Routine
Write your name on his whiteboard the moment you walk in — every person, every visit. Bob has expressive aphasia and cannot speak, but he understands everything. He watches that board as his way of knowing he's safe. When staff forget, his anxiety rises visibly within minutes. 11 shifts of consistent documentation on this.
Consistent across 11 shifts · all staff INR draw due before 9AM
Cognitive Triggers
Morning news orients him and immediately calms his early anxiety. Turn it on when he wakes — he gives a thumbs up when it's on. Also: he understands everything you say, including conversations about him in the room. Speak to him directly and normally. Don't slow down or over-enunciate. He notices when people don't.
Night CNA J. Ramirez · x6 shifts Carol visits 1PM — he tracks the clock
Unresolved Items
2 pending
Call Dr. Patel — Mary's BP + pain
BP 158/94 overnight, pain 7/10 uncontrolled. Night nurse couldn't reach — first hour priority.
George's daily weight not done
Before breakfast, same scale. Critical for CHF fluid monitoring — cannot be skipped.
Patient Quick View
Mary Johnson  ·  201A
Pain 7/10  ·  BP 158/94  ·  DNR
Critical
George Williams  ·  203B
CHF  ·  Weight due  ·  Family absent
Watch
Ravi Patel  ·  205A
Post-op knee  ·  PT 10AM
Stable
Sarah Kim  ·  207B
COPD exacerbation  ·  Day 1
New admit
Bob Carter  ·  210A
CVA / Aphasia  ·  INR due
Aphasia
How this was built
ShiftIQ read 12 hours of notes from T. Martinez, RN and 3 CNAs, extracted soft intelligence that doesn't normally transfer, and organized it by clinical category.
Pain patterns extracted6 entries
Family dynamics noted3 patients
Behavioral routines logged4 routines
Cognitive triggers flagged2 patients
Unresolved care gaps2 items
All five patient profiles are ready to explore.
Each shows a different dimension of ShiftIQ's intelligence layer — click any row to open the full chart.
Patient Census — 2-North
Day Shift  ·  7:00 AM  ·  5 patients  ·  2 need immediate attention
5
Total patients
2
Active alerts
3
Meds due by 9AM
4
AI care notes
201
BED A
Mary Johnson, 78F CriticalDNR
L-Hip Fracture Post-ORIF  ·  Dr. Patel  ·  Day 4  ·  Medicare A
Contact IsolationFall Risk HIGHPain 7/102 AI notes
158/94
BP
72
HR
94%
O2
"Always introduce yourself before touching her — she startles and is a fall risk when scared."
203
BED B
George Williams, 84M Watch
CHF / Post-CABG  ·  Dr. Chen  ·  Day 7  ·  Medicare A
Mild Confusion (eve)TelemetryFluid Restrict 1.5L1 AI note
132/78
BP
88
HR
97%
O2
"Family hasn't visited. He seems sad. Room temp OJ before meds. Check in extra today."
205
BED A
Ravi Patel, 71M
R-Knee Replacement  ·  Dr. Santos  ·  Day 2  ·  Medicare A
Progressing wellPT 10AM1 AI note
126/72
BP
76
HR
98%
O2
"Motivated to get home before his granddaughter's birthday — use it. PT at 10AM."
207
BED B
Sarah Kim, 66F
COPD Exacerbation  ·  Dr. Patel  ·  Day 1  ·  Blue Cross
O2 2L NCNebs 8AMNew Admit
138/82
BP
82
HR
95%
O2
"Day 1 — prefers tea, needs two pillows to breathe, ask about her home support situation today."
210
BED A
Bob Carter, 82M
CVA / Stroke Recovery  ·  Dr. Washington  ·  Day 11  ·  Medicare A
Aphasia — use boardINR due4 AI notes
142/86
BP
74
HR
98%
O2
"Write your name on his whiteboard before anything else. He pointed at the TV this morning — thumbs up."
BP 158/94 trending high  ·  Pain 7/10 unresolved  ·  Contact Isolation active  ·  DNR confirmed  ·  Call Dr. Patel this shift
Contact Isolation  —  Gown & Gloves required before entry  ·  MRSA precautions
Mary Johnson
DNRHigh Fall Risk
78F  ·  Room 201A  ·  L-Hip Fracture Post-ORIF  ·  Dr. Patel  ·  Day 4  ·  Medicare A  ·  DOB 03/14/1947
Allergies: Penicillin (anaphylaxis), Sulfa (rash)
Shift signals — right now
BP 158/94
Trending high · Call Dr. Patel
Pain 7/10
Tylenol inadequate · PRN available
O2 94%
Room air — reassess
BG Due 9AM
Last 214 · Sliding scale
SBAR Handoff Summary
From: T. Martinez, RN  ·  Night Shift
S
Situation
Mary Johnson, 78F, post-ORIF left hip fracture Day 4. BP trending high overnight — peaked 162/96 at 0300, currently 158/94. Pain 7/10 despite scheduled Tylenol. Contact isolation for MRSA. DNR confirmed.
B
Background
PMH: HTN, DM Type 2, osteoporosis. Baseline BP 130s/80s. Metoprolol 25mg BID + Lisinopril 10mg. BG running 180–220. Foley Day 3, site intact. Last BM Day 2 — Colace ordered.
A
Assessment
BP elevation likely pain-driven — Tylenol alone insufficient post-ORIF. May need PRN Oxycodone reassessment. O2 94% on room air — borderline. Confusion risk elevated.
R
Recommendation
Contact Dr. Patel re: pain + BP. Consider PRN opioid or Metoprolol adjustment. Reassess O2. Keep bed alarm on, rails up. Linda visiting this afternoon — do NOT offer procedure consent without her present.
Vitals
6:45 AM
Blood Pressure
158/94
Trending high
Heart Rate
72
Regular
O2 Sat
94%
Watch
Temp
98.4°
Afebrile
Resp Rate
16
Normal
Pain
7/10
Uncontrolled
Lines & Access
Peripheral IVR forearm · 2/16 · 20ga
IV FluidsNS @ 75mL/hr
FoleyDay 3 · Output adequate
Wound DrainL hip JP · 20mL overnight
O2Room air — reassess
Code StatusDNR confirmed
Neuro & Status
OrientationA&O x3 (not event)
ConfusionMild — especially nights
LungsClear bilaterally
DietADA 1800 · Mech. soft
Blood SugarLast 214 · Due 9AM
Last BMDay 2 · Colace ordered
Medications This Shift
3 due by 9AM
8:00 AM
Metoprolol 25mg PO
BP 158/94 — contact Dr. Patel before administering
Due Now
8:00 AM
Lisinopril 10mg PO
Hold if SBP <100
Due
9:00 AM
Insulin Sliding Scale
Check BG first — last 214 at 0300
Due
0300
Acetaminophen 650mg PO
Given overnight — pain 7/10, inadequate response
Given
PRN
Oxycodone 5mg PO
Last given 2400 · q4h PRN pain >5 · Reassess after
Available
Safety
Fall RiskHigh · Score 14
Bed AlarmOn · Verify each entry
Side RailsUp x3
Pressure UlcerStage 1 coccyx · Q2H turns
Tasks Due
Call Dr. Patel — BP + pain
Priority
Head-to-toe assessment
By 9AM
Blood glucose + insulin admin
Pain reassessment after PRN
Foley output documented
Pain Response Tracker
AI PATTERN · 4 SHIFTS
✦
Timing pattern detected across 4 shifts
Oxycodone 5mg alone at 0300 — partial relief only (8→5). Oxycodone 5mg given 45 min before PT on Day 3 — pain dropped to 3/10, best response this stay. The combination of Oxycodone timed 45–60 min before activity outperforms the same dose given at rest. The med isn't the full variable — timing relative to therapy is. Consider scheduling PRN dose around PT at 10AM and 2PM rather than waiting for peak pain.
Response log — last 4 doses
Time
Medication
Before
1hr After
Context
Day 3 · 21:00
Oxycodone 5mg
7/10
3/10 ↓
Given 45 min before PT · best response this stay
Day 3 · 03:00
Oxycodone 5mg
8/10
5/10 ↓
Woken from sleep — partial relief, no activity context
Day 2 · 14:00
Acetaminophen 650mg
6/10
6/10 →
No change — inadequate for post-ORIF at this dose
Day 1 · 20:00
Oxycodone 5mg
8/10
4/10 ↓
Evening — moderate relief, no PT scheduled that day
Log this dose — set 1hr reassessment reminder
Medication given
Pain score now
Context
AI Human Layer — Care Intelligence
4 shifts  ·  Night + Evening CNAs
Know before you go in
Introduce yourself before touching — every time Slow mornings — give her 15 min first Bible on bedside matters to her Linda visits 2PM · DNR contact · wait for her Pain scores are underreported — use behavioral cues Contact Isolation — gown + gloves, no exceptions
1
Always say your name before touching her. "Hi Mary, it's [name], I'm your nurse today." She wakes up frightened if she doesn't know who's in her room and will grab for the rail — she's a fall risk in those moments. Every person, every time.
2
Give her 10–15 minutes to orient before starting morning cares. Rushing increases agitation and her pain response measurably. A slow start saves time later and makes the whole interaction better.
3
Her daughter Linda is the DNR decision-maker and visits every afternoon around 2PM. Do not offer procedure consent or have goals-of-care conversations without Linda present. Mary becomes visibly calmer when Linda is there.
What the care team knows
Always introduce yourself before touching her. Documented across 3 shifts — she startles easily and is a fall risk when she doesn't know who is in her room.
Night CNA T. Vega  ·  x3 shifts
Mary does best with slow mornings. Give her 10–15 min to orient before starting cares. Rushing increases agitation and her pain response measurably.
Day RN S. Okafor  ·  x2 shifts
Her daughter Linda is the primary family contact and DNR decision-maker. Visits every afternoon around 2PM. Do not offer consent without her present.
Charge RN M. Brooks  ·  Day 1
She is religious and her Bible on the bedside table is important to her. A warm "good morning, Mary" goes a long way.
Evening CNA R. Torres  ·  Day 3
AI-flagged gaps
What foods or drinks make Mary happy?
4 shifts of data — no food preferences captured yet. Appetite affects pain tolerance.
Bathing preference — sponge or basin?
Not documented. Ask this morning during AM care.
Concerns about going home?
She mentioned living alone once — flag for social work at discharge planning.
Pain underreporting pattern — documented
Use behavioral cues (grimacing, guarding) alongside reported score.
Code status confirmed — DNR paperwork on chart
Daily weight NOT done  ·  Fluid compliance dropping  ·  Family absent 6 days  ·  Sundowning risk this evening
George Williams
WatchTelemetry
84M  ·  Room 203B  ·  CHF / Post-CABG  ·  Dr. Chen  ·  Day 7  ·  Medicare A  ·  Full Code
Allergies: Aspirin (GI bleed), Codeine (nausea)
Shift signals — right now
Weight Not Done
Must be before breakfast
Same scale always
Fluid 1,500mL
Compliance slipping
Track every input
Telemetry On
HR 88 · Watch for AFib
1+ ankle edema
Family Absent
6 days · Compliance link
Daughter not contacted
SBAR Handoff Summary
From: J. Okafor, RN  ·  Night Shift
S
Situation
George Williams, 84M, CHF / post-CABG Day 7. Daily weight not completed — must be done before breakfast, same scale. HR 88 on telemetry, 1+ bilateral ankle edema. Fluid intake tracking inconsistent overnight.
B
Background
PMH: CHF (EF 35%), post-CABG x3, AFib (paroxysmal), DM2. On Lasix 40mg QD, Carvedilol 6.25mg BID, Lisinopril 5mg. Baseline weight 187 lbs. Fluid restriction 1,500mL/day. Aspirin allergy — GI bleed. Codeine allergy — nausea.
A
Assessment
Fluid compliance declining since daughter's last visit 6 days ago — staff-documented pattern. Edema worsening slightly. Sundowning risk increases after 1800. Mood quieter than baseline this morning. Weight gap is the highest-priority task.
R
Recommendation
Weight before breakfast — same scale, same time. Document all fluids. Notify Dr. Chen if weight up >2 lbs. Prep room-temp OJ for morning meds. Confirm daughter contact per family communication plan. Watch for AFib on telemetry.
Vitals
6:50 AM
Blood Pressure
132/78
Stable
Heart Rate
88
Slightly elevated
O2 Sat
97%
2L NC
Temp
97.8°
Afebrile
Resp Rate
14
Normal
Pain
3/10
Controlled
Lines & Monitoring
IV AccessL AC · saline lock · 2/14
TelemetryOn · Watch for AFib
O22L Nasal Cannula
Fluid Restrict1,500mL/day — track all
Daily WeightDUE — before breakfast
CodeFull Code
Neuro & Status
OrientationA&O x4 this AM
ConfusionSundowning — worse evenings
Lung SoundsMild bibasilar crackles
Edema1+ bilateral ankles
Diet2g Sodium · Cardiac
MoodQuieter than baseline
Medications This Shift
3 due by 9AM
8:00 AM
Carvedilol 6.25mg PO
Give with food · Hold if HR <55 or SBP <90
Due
8:00 AM
Lisinopril 5mg PO
Hold if SBP <100 · Check weight before giving
Due
8:00 AM
Lasix 40mg PO
Daily diuretic — give after weight, monitor urine output
Due
0200
Metformin 500mg PO
DM2 management — given overnight
Given
PRN
Lorazepam 0.5mg PO
PRN anxiety / agitation — sundowning risk · Use cautiously
PRN
Safety
Fall RiskModerate — bed alarm on
RestraintsNone
WanderingSundowning — check evenings
Diet SafetyNo Aspirin in any form
Tasks Due
Daily weight — before breakfast, same scale
Priority
Fluid intake documentation — all inputs
Ongoing
Notify Dr. Chen if weight up >2 lbs
Contact daughter per family plan
Lung sounds reassessment post-Lasix
Telemetry strips reviewed overnight
AI Human Layer — Care Intelligence
7 shifts  ·  Family dynamics pattern confirmed
Know before you go in
Room-temp OJ before meds — every morning, without exception When daughter visits, fluid compliance is near-perfect Morning news orients him — turn it on when he wakes Sundowning worsens after 6PM — redirect early Former carpenter — compliments on the room work well
1
His daughter's visits directly predict his fluid compliance — this is fully documented across 7 shifts. When she's here, he restricts voluntarily. When she isn't, he drifts without noticing. Day 7 is a good time to contact her directly with a care update.
2
Bring him room-temperature OJ before meds. Dietary can prep it. Cold liquids cause nausea for him — documented by night CNAs on three consecutive shifts. This one small thing sets the tone for morning cares.
3
Sundowning escalates quickly after 6PM. Redirect early — before confusion peaks. Morning news on wake-up resets orientation and gives him context for the day. Night shift has noted it's the most effective non-pharmacological intervention for him.
What the care team knows
When his daughter visits, his fluid compliance is nearly perfect. Without her, he accepts refills without tracking. The correlation is documented in 5 of 7 shifts. It's behavioral, not cognitive — he simply doesn't self-monitor alone.
Multiple CNAs  ·  x5 shifts
Morning news orients him and improves his cooperation for at least two hours. Night CNA J. Ramirez noted this on Day 3 and it's been confirmed on every subsequent shift. He watches closely and responds to it.
CNA J. Ramirez  ·  x4 shifts
Room-temperature OJ before morning meds prevents nausea. Three consecutive night CNAs documented this independently. Cold liquids cause visible discomfort. Dietary can set it up — it takes 30 seconds and significantly improves his morning cooperation.
Night CNAs  ·  x3 shifts
AI-flagged gaps
Has daughter been contacted about the 6-day absence?
Family communication plan active — document outreach this shift.
Evening sundowning protocol in place?
Evening staff should know the redirect strategies documented in shifts 3–6.
Morning OJ preference — dietary notified, all shifts confirmed
Family dynamics / fluid compliance pattern — documented and flagged
Day 2 · Progressing well  ·  PT at 10AM — prep and 2-assist needed by 9:45  ·  BG before breakfast
Ravi Patel
Progressing WellPT 10AM
71M  ·  Room 205A  ·  R-Knee Replacement  ·  Dr. Santos  ·  Day 2  ·  Medicare A  ·  Full Code
Allergies: NKDA  ·  Diabetic — BG Q6H
Shift signals — right now
Pain 3/10
Well controlled · post-op Day 2
BG Due 9AM
Last 138 · diabetic protocol
PT at 10AM
2-assist ready by 9:45
Stairs evaluation today
Motivated
Granddaughter's birthday
is his discharge goal
SBAR Handoff Summary
From: S. Okafor, RN  ·  Night Shift
S
Situation
Ravi Patel, 71M, post R-knee replacement Day 2. Pain 3/10 — well controlled overnight. BG due before breakfast. Wife called at 0800 as expected — he was in good spirits after. PT at 10AM, 2-assist, stairs evaluation today.
B
Background
PMH: DM Type 2 (Metformin 500mg, sliding scale insulin). NKDA. Retired civil engineer, 71 years old. Baseline active — walks daily. BG running 128–144. Wound: R knee incision intact, no drainage. PIV R forearm saline lock.
A
Assessment
Pain well controlled — appropriate post-op Day 2 trajectory. BG stable, no sliding scale needed overnight. Strong motivation, good engagement with staff. No ambulation pain captured yet — PT needs movement baseline before stairs eval.
R
Recommendation
BG before breakfast. Oxycodone PRN if pain >4 before PT. Have him ready by 9:45 — 2-assist, walker, knee immobilizer. Use his granddaughter's birthday as motivation. Ask about home setup for case management and discharge planning.
Vitals
6:40 AM
Blood Pressure
126/72
Stable
Heart Rate
76
Normal
O2 Sat
98%
Room air
Temp
98.1°
Afebrile
Resp Rate
16
Normal
Pain
3/10
Controlled
Lines & Access
Peripheral IVR forearm · saline lock
O2Room air · no support needed
WoundR knee incision intact · no drainage
DrainNone
FoleyNone · ambulating to BR
CodeFull Code
Neuro & Status
OrientationA&O x4 · Clear
MoodMotivated · strong engagement
DietRegular · Diabetic
Blood SugarLast 138 · Due 9AM
Mobility2-assist · NWB R leg
SleepRested well overnight
Medications This Shift
2 due by 9AM
9:00 AM
Blood glucose check + insulin sliding scale
Last 138 — check before breakfast, document before meds
Due
8:00 AM
Oxycodone 5mg PO
Scheduled post-op · pain 3/10 · Give before PT if >4
Due
0600
Aspirin 81mg + Metformin 500mg
DVT prophylaxis + DM2 management · given
Given
PRN
Ondansetron 4mg IV
Nausea PRN — not needed overnight
PRN
Safety
Fall RiskModerate · NWB R leg
Ambulation2-assist · walker + knee immobilizer
Bed AlarmOn at all times
PT Assist2-person required · DO NOT allow solo
Tasks Due
BG check before breakfast
9AM
PT prep — 2-assist ready by 9:45
10AM
Wound assessment — R knee dressing
Ask about home setup — stairs, support at home
Vitals documented — night shift
AI Human Layer — Care Intelligence
Day 2  ·  Profile building
Know before you go in
Granddaughter's birthday is his discharge goal — use it clinically Wife calls 8AM — he's more cooperative for an hour after BG before meds, every time — diabetic protocol Retired engineer — explain the why, he engages better
1
He wants to be home before his granddaughter's birthday next week. This is documented from Day 1 intake and referenced by every staff member. Use it — when he pushes back on an exercise or resists rest, framing it around his goal lands better than any clinical instruction.
2
His wife calls every morning around 8AM and he's visibly in better spirits for at least an hour after. If you're timing PT prep or morning meds, give him those 10 minutes first — compliance improves meaningfully.
3
He's a retired civil engineer — he wants to understand the clinical reasoning, not just be told what to do. "Your knee is swollen because..." gets more buy-in than "we need you to elevate your leg." Takes 30 extra seconds and makes a real difference.
What the care team knows
He mentioned his granddaughter's birthday during intake, and again on every staff check-in on Day 1. It's his primary discharge motivator — all staff should reference it when framing cares.
Admitting RN  ·  Day 1 intake
Wife calls every morning around 8AM — he is noticeably more upbeat and cooperative for at least an hour after. Night CNA documented this on Day 1. Time morning cares to follow the call if possible.
Night CNA  ·  Day 1
Civil engineer for 35 years. Explain the clinical rationale behind each intervention — he listens, he processes logically, and he complies when he understands the reason. This was self-reported at intake and confirmed by night staff.
Patient self-report  ·  Day 1 intake
AI-flagged gaps
Pain during ambulation vs. at rest?
Resting pain captured. PT needs movement baseline before stairs evaluation.
Home setup — stairs, support person available?
Case management needs this for discharge planning. Ask today.
Discharge motivator captured — granddaughter's birthday, all staff aware
Morning call window noted — schedule cares accordingly
Day 1 admission  ·  O2 2L NC continuous  ·  No care preferences captured yet  ·  Ask what makes her comfortable this shift
Sarah Kim
O2 2L NCNew Admit
66F  ·  Room 207B  ·  COPD Exacerbation  ·  Dr. Patel  ·  Day 1  ·  Blue Cross  ·  Full Code
Allergies: Penicillin (rash)
Shift signals — right now
O2 2L NC
Continuous · SpO2 95%
Target ≥92%
Nebs Due 8AM
Albuterol Q4H · first dose
Alert & Oriented x4
Cooperative · clear communicator
Profile Building
Day 1 — capture preferences
every interaction
SBAR Handoff Summary
From: R. Nguyen, RN  ·  Night Shift (Admission RN)
S
Situation
Sarah Kim, 66F, admitted overnight for COPD exacerbation Day 1. On 2L nasal cannula continuously — SpO2 95%, target ≥92%. Productive cough, diminished at bases. Albuterol nebs Q4H, first AM dose due now. Low-grade temp 99.1°. Alert and communicative throughout admission.
B
Background
PMH: COPD (moderate), HTN. Penicillin allergy — rash. Presented via ED with 3-day worsening dyspnea. Prior hospitalization history unknown at this time. Lives alone — home support not yet confirmed. No family contact listed on admission paperwork.
A
Assessment
Responding to treatment — O2 maintaining. Mildly elevated resp rate at 18, productive cough continues. Patient is clear, engaged, and asking good questions about her plan of care. Day 1 — significant profile gaps remain. Home situation unknown, support person not identified.
R
Recommendation
Albuterol nebs 8AM, incentive spirometry Q1H while awake, HOB 30–45° at all times (two pillows preferred). Confirm primary contact person — she may live alone. Bring tea not coffee. Capture preferences each interaction — this is the best window to build her profile before she's stressed.
Vitals
6:55 AM
Blood Pressure
138/82
Stable
Heart Rate
82
Normal
O2 Sat
95%
On 2L NC
Temp
99.1°
Low-grade
Resp Rate
18
Slightly elevated
Pain
2/10
Minimal
Respiratory & Lines
O2 Delivery2L Nasal Cannula · continuous
NebsAlbuterol Q4H · Due 8AM
Lung SoundsDiminished at bases
ISIncentive spirometry Q1H awake
IV AccessL forearm · saline lock
CodeFull Code
Neuro & Status
OrientationA&O x4 · fully communicative
MoodCalm · asking good questions
CoughProductive · monitor frequency
HOB30–45° always · two pillows
Mobility1-assist · short distances only
DietRegular · tolerating
Medications This Shift
2 due by 9AM
8:00 AM
Albuterol 2.5mg neb treatment
Q4H · COPD exacerbation · first AM dose
Due
8:00 AM
Methylprednisolone 40mg IV
COPD exacerbation · AM dose
Due
0200
Lisinopril 10mg PO
HTN management · given overnight
Given
PRN
Azithromycin 500mg PO
Antibiotic coverage · pending culture results
Pending
Safety
Fall RiskModerate · dyspnea with exertion
O2 ContinuityNever disconnect without assessment
HOB Position30–45° always — patient-reported need
PenicillinAllergy confirmed — rash · check all ABX
Tasks Due
Albuterol neb treatment — 8AM first dose
Due
Confirm primary contact / does she live alone?
Priority
Incentive spirometry — Q1H while awake
Lung sounds post-neb reassessment
Admission vitals and O2 documented
AI Human Layer — Profile Building
Day 1  ·  First shift
What to ask and note this shift
Home Support
Does she live alone? Who is her primary contact? Critical for safe discharge planning from Day 1.
COPD History
Has she been hospitalized before? What does she do at home when she feels a flare starting?
Sleep & Comfort
Anything else she needs to sleep well here? Room temperature preference? How does she manage breathing at night at home?
Morning Routine
Early riser or slow starter? How does her breathing typically feel in the morning? Any rituals that help her feel oriented?
What we already know — from intake
Sleeps with two pillows — HOB 30–45° is non-negotiable Prefers tea over coffee in the mornings Clear communicator — she will tell you what she needs Engaged and asking good questions about her care plan
Captured at intake
She sleeps with two pillows at home and finds it hard to breathe lying flat. HOB 30–45° is not a positioning preference — it's a respiratory need. She flagged this herself during intake. All staff must maintain it.
Patient self-report  ·  Night RN  ·  Admission
She prefers tea over coffee in the mornings. Small detail, but a good morning start on Day 1 builds trust quickly when everything else is unfamiliar. Night CNA noted this after the admission conversation.
Patient self-report  ·  Night CNA  ·  Admission
Alert, engaged, and asking good questions about her plan of care throughout admission. She is a clear, capable communicator who will advocate for herself. Respond to her questions directly — she wants to understand what's happening.
Admitting RN  ·  Day 1 intake
Open gaps — capture this shift
Does she live alone? Primary contact?
No family contact listed — critical for safe discharge from Day 1.
Previous COPD hospitalizations?
History frequency matters for treatment and readmission risk modeling.
HOB position need confirmed — two pillows, 30–45°. All staff notified.
Morning preference captured — tea, not coffee.
Write your name on his whiteboard before doing anything else  ·  Every person  ·  Every visit  ·  Without exception
Bob Carter
Expressive AphasiaINR Due
82M  ·  Room 210A  ·  CVA / Stroke Recovery  ·  Dr. Washington  ·  Day 11  ·  Medicare A  ·  Full Code
Allergies: Warfarin sensitive — INR monitoring required  ·  No other known allergies
He CAN
Understand everything spoken to him. Read. Communicate with nods, gestures, and the communication board. He tracks time and anticipates Carol's visit.
He CANNOT
Speak expressively. He knows exactly what he wants to say. Never finish his sentences, never guess for him. Give him time to point or use the board.
What Works
Name on whiteboard first. Talk normally — don't slow down. Narrate what you're doing as you do it. Use the communication board for any choices or questions.
Shift signals — right now
Write Name First
Whiteboard · every visit
11 shifts confirmed
INR Draw Due
Warfarin monitoring
Draw before 9AM
Vitals Stable
Day 11 · no acute issues
progressing
Carol Visits 1PM
Daily · highly engaged
he tracks the clock
SBAR Handoff Summary
From: M. Torres, RN  ·  Night Shift
S
Situation
Bob Carter, 82M, CVA Day 11. Expressive aphasia — comprehension fully intact. INR draw due before 9AM for Warfarin monitoring. Vitals stable overnight. Responded well to morning news on at 0600 — gave thumbs up, calm and cooperative for overnight cares. Carol visiting today at 1PM as usual.
B
Background
PMH: Left MCA CVA, HTN, AFib (on Warfarin). Expressive aphasia — comprehensive intact. Former civil engineer, 35 years. Dysphagia — SLP confirmed nectar thick liquids Day 3. PIV R AC saline lock. Daily PT. Wife Carol is primary support, visits daily at 1PM, highly engaged in care planning.
A
Assessment
Neurologically stable. Anxiety controlled through consistent routine — whiteboard + morning news + Carol's visit are the three anchors. INR due and must be drawn before 9AM. Communication board at bedside confirmed. Augmentative device trial pending SLP update.
R
Recommendation
Write your name on the whiteboard before anything else. Turn on morning news. Draw INR before 9AM. Nectar thick liquids only — no exceptions. During Carol's 1PM visit, ask her about his pre-stroke preferences — she knows him better than the chart does. Follow up with SLP on augmentative device trial status.
Vitals
6:48 AM
Blood Pressure
142/86
Stable
Heart Rate
74
Regular
O2 Sat
98%
Room air
Temp
97.9°
Afebrile
Resp Rate
15
Normal
Pain
2/10
Via board gestures
Lines & Meds
IV AccessR AC · saline lock
INR DrawDue before 9AM · Warfarin
O2Room air · no support needed
SwallowNectar thick only · SLP Day 3
CommunicationBoard at bedside · always use it
CodeFull Code
Neuro & Mobility
SpeechExpressive aphasia
ComprehensionFully intact · hears everything
OrientationOriented · tracks time and visits
Mobility1-assist · PT daily
ContinenceUrinal with assist
AnxietyVisible when whiteboard skipped
Medications This Shift
INR before 9AM
Before 9AM
INR draw — Warfarin monitoring
Warfarin sensitive — dose adjusted per result. Draw and send before medications.
Due Now
8:00 AM
Lisinopril 10mg PO
HTN management · give with nectar thick liquid
Due
0600
Aspirin 81mg PO (nectar thick)
Secondary stroke prevention · given overnight
Given
Per INR
Warfarin — dose pending INR result
Do not give until result received and Dr. Washington notified
Pending
Safety
Fall RiskHigh · 1-assist always
SwallowNectar thick ONLY · no exceptions
AnticoagWarfarin · monitor for bleeding
CommunicateAlways use board for questions
Tasks Due
Write name on whiteboard — before anything else
First
INR draw — before 9AM
Priority
Morning news on when he wakes
Ask Carol about pre-stroke preferences — 1PM visit
Follow up with SLP on augmentative device trial
Communication board at bedside confirmed
AI Human Layer — 11 Shifts of Intelligence
Strongest profile on the floor
Know before you go in
Name on the whiteboard — do it before anything else in the room Morning news orients and calms him immediately Carol visits 1PM daily — he tracks the clock toward it Civil engineer 35 years — narrate what you're doing, he processes by sequence Never guess what he's trying to say — let him use the board Nectar thick only — dysphagia confirmed by SLP
1
Write your name on his whiteboard before you do anything else in the room. Confirmed by every CNA and RN across all 11 shifts — when staff do this, he's calm and cooperative. When they forget, visible anxiety rises within minutes. This is the single highest-impact 5-second action in his chart.
2
Morning news is his orienting anchor. Turn it on when he wakes. He watches it closely, gives a thumbs up, and it sets the tone for the entire morning. Without it, he's noticeably more unsettled and more difficult to engage for cares.
3
He understands everything — speak to him exactly as you would any other patient. Don't slow down, over-enunciate, or talk about him as if he isn't there. He worked as a civil engineer for 35 years. He notices. Narrate what you're doing as you do it: "I'm going to take your blood pressure now, Bob."
What 11 shifts built
Name on the whiteboard is the most documented care pattern in the chart — confirmed independently by every CNA and RN across all 11 shifts. Calm when done, anxious when skipped. Not a suggestion.
All staff  ·  11 shifts
Morning news is his daily orienting anchor. He watches it closely and it consistently sets the tone for the morning. Without it, he's more unsettled and harder to engage. Documented on 6 consecutive shifts by the same night CNA.
Night CNA J. Ramirez  ·  x6 shifts
Wife Carol visits daily at 1PM and is deeply engaged in his care. He begins tracking the clock toward her visit by mid-morning. She knows his pre-stroke baseline better than any chart — she's an underused clinical resource.
Multiple staff  ·  x9 shifts
He responds well when staff narrate what they're doing as they do it. "I'm going to check your BP now, Bob." Matches how he processes — sequentially, logically. Day RN S. Okafor documented this on four shifts and it's been confirmed since.
Day RN S. Okafor  ·  x4 shifts
Gaps & open questions
Augmentative communication device trialed?
SLP evaluation ongoing — get update this shift.
Carol's knowledge of pre-stroke preferences?
Schedule time during today's 1PM visit — she's the best source.
Communication board at bedside — all staff confirmed
Dysphagia diet confirmed — nectar thick  ·  SLP Day 3
Whiteboard + morning news routine — all staff aligned across 11 shifts
Task List
Day Shift  ·  K. Reynolds, RN  ·  6 items total  ·  2 are first-hour priority
Priority Tasks
Do first
Call Dr. Patel — Mary's BP (158/94) + pain (7/10) unresolved from night
201A
George daily weight — before breakfast, same scale, for CHF monitoring
203B
Mary head-to-toe assessment + isolation verification
By 9AM
Sarah Kim neb treatment — due 8AM, COPD Day 1
207B
Bob Carter INR draw — anticoag therapy, write name on board first
210A
Mary blood glucose check + insulin admin per sliding scale
9AM
Ongoing This Shift
Mary Q2H repositioning — Stage 1 coccyx, document each turn
George fluid intake tracking — 1,500mL/day limit
Ravi Patel PT prep at 9:45AM — 2-person assist, therapy room
Mary pain reassessment after PRN opioid administration
Sarah Kim O2 titration check — target SpO2 ≥92% on 2L NC
George social work consult — family absence Day 6, flag for contact
Foley output documented — Mary (night shift)
CNA Floor View
Day Shift  ·  5 patients  ·  2 patients need extra attention this morning
201A
Mary Johnson
78F · Hip Fracture · Day 4
Critical
Bathing
Total assist
Turning
Q2H — coccyx
Mobility
2-assist NWB
Isolation
Contact · Gown
Say your name before touching her — every time. She startles and is a fall risk.
203B
George Williams
84M · CHF · Day 7
Watch
Weight
AM · Same scale
Fluids
Track all · 1,500mL
Diet
2g Sodium
Bathing
Assist in bathroom
Request room-temp OJ from dietary before his meds. Family absent 6 days — be extra warm today. Morning news helps orient him.
205A
Ravi Patel
71M · Knee Replacement · Day 2
Stable
Mobility
2-assist · PT 10AM
Bathing
Partial assist
Blood Sugar
Due 9AM
Diet
Regular · Diabetic
Motivated to get home. PT at 10AM — have him prepped and ready by 9:45.
207B
Sarah Kim
66F · COPD · Day 1
New admit
O2
2L NC continuous
Nebs
Due 8AM
Mobility
1-assist short dist.
Position
HOB 30–45°
Day 1 — no preferences captured yet. Ask what makes her comfortable. Note anything she mentions.
210A
Bob Carter
82M · CVA / Aphasia · Day 11
Aphasia
Communication
Board always
Whiteboard
Write name FIRST
Mobility
1-assist · PT daily
Diet
Nectar thick
Write your name on his whiteboard before doing anything else. He understands everything — talk to him normally. Use the communication board for all requests.
Care Intelligence
1
Write your name on his whiteboard the moment you walk in. Bob cannot speak but understands everything. That whiteboard is how he knows who's in his room and that he's safe. When staff forget, his anxiety rises within minutes.
2
Use yes/no questions only — thumbs up for yes, thumbs down for no. He established this system on Day 2 and it's consistent. Never ask open-ended questions or finish his sentences. He gets frustrated when people assume his answer before he signals it.
3
His wife Carol visits every afternoon around 1PM. He lights up visibly when she arrives — mood and cooperation both improve for the rest of the day. If he seems withdrawn in the morning, her visit later is worth mentioning.
Day 1 New Admit  ·  Moderate disorientation — doesn't know where she is  ·  Sundowning risk starting ~3PM  ·  Daughter Rachel on-site, very anxious  ·  No prior SNF history
Memory Care Protocol Active  ·  Wandering precautions  ·  Reorientation every 2hrs  ·  Familiar items from home requested  ·  Minimize room changes
Dorothy Chen
Memory Care High Wander Risk Day 1 Admit
84F  ·  Room 212A  ·  Moderate Alzheimer's (CDR 2)  ·  Dr. Nguyen  ·  Day 1  ·  Medicare A  ·  DOB 06/22/1941
Allergies: Codeine (nausea/vomiting)
Shift signals — right now
Disoriented
Doesn't know location
Sundowner Risk
Starts ~3PM · plan now
Family Anxiety
Rachel on-site · needs briefing
No SNF History
First facility stay ever
Pain Unclear
Can't self-report reliably
SBAR Handoff Summary
Admit · ED Nurse K. Yamamoto
S
Situation
Dorothy Chen, 84F, moderate Alzheimer's (CDR Stage 2). Admitted from home following a fall — no fracture confirmed on imaging. Daughter Rachel (primary caregiver) brought her in. Dorothy is asking repeatedly where she is and when she's going home. She does not recognize this as a care facility.
B
Background
Diagnosed Alzheimer's 3 years ago, living at home with Rachel providing daily care. No prior SNF stays — this is her first time in a facility. Baseline per Rachel: speaks Cantonese and English, loves Mahjong and Cantonese opera, always watches the 6PM news, sleeps with a specific yellow blanket from home. History of sundowning at home starting around 3–4PM — agitation, attempts to leave, calling for her late husband Henry.
A
Assessment
High agitation risk this afternoon as sundowning window opens. Pain assessment unreliable — she cannot self-report consistently. Watch for behavioral cues: facial grimacing, guarding her right hip, reduced movement, increased vocalizations. Wander risk is significant — she has attempted to leave twice at home in the past month. Rachel is overwhelmed and needs a clear update from clinical staff before she'll feel safe leaving.
R
Recommendation
Brief Rachel within the hour — she needs a care plan walkthrough and visiting schedule before she'll leave. Ask Rachel to bring the yellow blanket, a Mahjong set, and a photo of Henry from home today. Activate sundowning protocol by 2:30PM. Check wander sensor on door before end of morning shift. Pain assessment: use PAINAD scale — behavioral observation only, not self-report.
Vitals
8:10 AM · Admit
Blood Pressure
118/72
Stable
Heart Rate
78
Regular
O2 Sat
97%
Room air
Temp
98.1°
Afebrile
Resp Rate
16
Normal
Pain (PAINAD)
4/10
Behavioral cues
Cognitive Status
DiagnosisAlzheimer's — CDR Stage 2
OrientationPerson only — not place/time
LanguageEnglish + Cantonese
Pain ScalePAINAD — behavioral only
SundowningStarts ~3–4PM · plan active
Wander RiskHigh · sensor required
Safety
Wander Sensor⚠ Verify before noon
Door AlarmActive · 212A
Fall RiskHigh · Score 16
Bed AlarmOn · verify each entry
Side RailsUp x2 · padded
Code StatusFull code — Rachel confirmed
Medications This Shift
2 due by 10AM
9:00 AM
Donepezil 10mg PO
Daily · crush and mix in applesauce — she will not swallow whole tablets
Due
9:00 AM
Lisinopril 5mg PO
Hold if SBP <100 · BP 118/72 at admit — give as scheduled
Due
PRN
Lorazepam 0.5mg PO
PRN severe agitation only · PAINAD ≥7 or elopement attempt · notify Dr. Nguyen first
PRN
PRN
Acetaminophen 500mg PO
PRN pain · PAINAD ≥4 · crush in applesauce · NO codeine — allergy
PRN
Tasks Due — This Shift
Brief Rachel — care plan + visiting schedule
Priority
Verify wander sensor on 212A door
By noon
Administer Donepezil + Lisinopril (in applesauce)
PAINAD assessment — document behavioral cues
Request blanket + photo + Mahjong set from Rachel
Activate sundowning protocol by 2:30PM
Reorientation check every 2 hours — document
Sundowning Protocol — Active 2:30PM
ACTIVATE 2:30PM
Environmental
Close curtains, dim overhead lights by 3PM
Turn on 6PM news (she always watches it)
Yellow blanket on bed before 3PM
Cantonese opera playlist — ask Rachel for favorites
Communication
• If she asks for Henry: "Henry asked us to take care of you today."
• If she asks to go home: "You're resting here for a little while, then we'll get you home."
• Do not correct or argue — redirect to familiar activity
• Call Rachel if agitation reaches PAINAD ≥6 — she wants to be here for severe episodes
AI Human Layer — Day 1 Intelligence
From: Rachel Chen · ED handoff · Admit notes
Know before you go in
Always say your name AND that Rachel sent you Cantonese preferred when distressed — "mei si" = it's okay Henry is her late husband — never say he's gone Mahjong calms her more than any medication Watch right hip — grimacing/guarding = pain, she won't tell you Yellow blanket from home = immediate comfort anchor
1
Introduce yourself and mention Rachel every time you enter. "Hi Dorothy, I'm [name] — Rachel asked me to check on you." Rachel is the trust anchor. Using her name immediately reduces Dorothy's alarm response. Do not skip this even if she seems calm.
2
She will ask for Henry. Do not tell her he passed away. It causes acute grief every time she hears it — she can't retain the information. Instead say: "Henry asked us to take good care of you today." This is what Rachel does at home and it works consistently.
3
Pain cannot be self-reported. Use PAINAD — watch for grimacing when repositioning, guarding the right hip, increased vocalizations, or withdrawal from touch. Her codeine allergy is on the med list. Acetaminophen in applesauce is the first line — she will refuse tablets.
What Rachel told us
She recognizes yellow as her comfort color — her blanket, her favorite teacup at home, her reading chair are all yellow. The yellow blanket is the single most important comfort item to bring today.
Rachel Chen · Daughter · Admit
At home, Mahjong stops a sundowning episode faster than anything else — even mid-agitation. She can still play from muscle memory even when she can't hold a conversation. Rachel is bringing a travel set this afternoon.
Rachel Chen · Daughter · Admit
She still speaks Cantonese when distressed — even if she was speaking English moments before. "Mei si" (没事) means "it's okay" and she responds to it. Rachel said it's the fastest way to de-escalate when she's frightened.
Rachel Chen · Daughter · Admit
AI-flagged priorities — Day 1
What does Dorothy call this facility?
She may have a word or frame that feels less frightening. Ask Rachel — using that language in reorientation reduces agitation.
Best time of day for personal care?
Ask Rachel if Dorothy is a morning or afternoon person before sundowning starts. Bathing during the wrong window dramatically increases agitation risk.
Favorite foods or comfort snacks?
No food preferences in chart yet. A familiar food at 3PM before sundowning window may help. Rachel will know.
Codeine allergy documented and flagged on med list
All pain PRNs use acetaminophen only. Confirmed with admitting MD.
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