Clinical BPGs
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A tool to assist with comparing your organization’s current practice with evidence-based RNAO best practice recommendations.
Registered Nurses Association of Ontario (2023) . Gap Analysis-Transitions in Care and Service, 2nd edition. Toronto, ON
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The purpose of the Transitions in Care and Services guideline is to provide evidence-based recommendations for nurses and members of the interprofessional team, organizations and the health system to support safe and effective transitions in care for pediatric (17 years and younger) and adult (18 years and older) persons and their support network. This BPG recognizes that persons and their support network who are encountering a transition in care are experts in their health and decision-making. Collaboration among the interprofessional team, the person receiving care and their support network is therefore essential to achieving improved health outcomes.
This BPG replaces the RNAO BPG Care Transitions published in 2014 (5).
https://rnao.ca/bpg/guidelines/transitions-in-care
Registered Nurses’ Association of Ontario (RNAO). Transitions in care and services. 2nd ed. 2023, Toronto (ON).
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5 Questions to Ask about Your Medications is a guide to help persons and their support network start conversations with health providers about their medications (168). Ensuring persons are active partners in their care, and ensuring they receive important information about their medications helps promote medication safety. It may be particularly helpful for persons to ask the following five questions about their medications when attending appointments with their primary care providers, communicating with their community pharmacist, and when preparing for a transition from hospital to home. The 5 Questions to Ask About Your Medications resource is available in 30 languages.
Source: Reprinted with permission from: Institute for Safe Medication Practices (ISMP) Canada, The Canadian Patient Safety Institute (CPSI), Patients for Patient Safety Canada (PFPSC), et al. 5 questions to ask about your medications [Internet]. Toronto (ON): ISMP Canada; 2016. Co-published with CPSI and CFPSC. Available from: https://www.ismp-canada.org/download/MedRec/MedSafety_5_questions_to_ask_poster.pdf.
Registered Nurses' Association of Ontario. (2023). Appendix K of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp. 128 .
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This interview guide from Alberta Health Services provides a list of questions health providers can ask when conducting a best possible medication history.
Source: Reprinted with permission from: Alberta Health Services (AHS). Best possible medication history (BPMH) interview guide [Internet]. Edmonton (AB): AHS; 2014. Available from: https://www.albertahealthservices.ca/assets/info/hp/medrec/if-hp-medrec-provider-interview-brochure.pdf © 2014 Alberta Health Services. This material is protected by Canadian copyright law. Except as otherwise provided for under Canadian copyright law, this material may not be copied, published, or distributed without the prior written permission of the copyright owner. This material was originally published by Alberta Health Services and has been reprinted with permission.
Registered Nurses' Association of Ontario. (2023). Appendix I of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp. 125.
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Findings from a quality improvement project which aimed to focused on understanding the problems related to information exchanges between nurses.
Retrieved from: https://www.canadian-nurse.com/blogs/cn-content/2015/03/03/communicate-with-me-information-exchanges-between
Christine Johnson, RN, MN, GNC(C), is a Clinical Nurse Specialist in the Rehab and Geriatric Program, Health Sciences Centre, Winnipeg. Tricia Carta, RN, MN, is a Clinical Nurse Specialist in the Burn Program, Health Sciences Centre. Karen Throndson, RN, MN, is a Clinical Nurse Specialist in the Cardiac Program, Health Sciences Centre.
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This article looks at communication as being a key culprit in compromising patient safety in hand-over. Suggestions are given for strategies on how to approach hand-overs from shift to shift consistently, how to include patient and family along with potential barriers
Reference: World Health Organization. (2007) Patient Safety Solutions. Communication during patient handovers. 1 (3). Retrieved from: https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/psf/patient-safety-solutions/ps-solution3-communication-during-patient-handovers.pdf?sfvrsn=7a54c664_4&ua=1
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This practice guideline provides an overview of the major features of the legislation, pertinent definitions, the steps nurses need to take to obtain consent and the Guidelines for Nurses Advocating for Clients Found Incapable of Making Certain Decisions. It replaces an earlier Guide to the Health Care Consent and Substitute Decisions Legislation for RNs and RPNs. It does not address consent under the Mental Health Act.
Reference: College of Nurses of Ontario Practice Guideline (2009) Consent Retrieved from: http://www.cno.org/globalassets/docs/policy/41020_consent.pdf
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This paper from the Institute for Safe Medication Practices in Canada (ISMP). A multi-incident analysis of delayed medication doses after transitions of care.
Reference: Institute for Safe Medication Practices in Canada (2016) Delayed Treatment after Transitions of Care: A Multi-Incident Analysis Retrieved from: https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-07-DelayedTreatment.pdf?utm_source=safetybulletin&utm_medium=email&utm_campaign=sbv16i07#page=1
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This tips and tools guide is designed to assist you to better understand and learn how to plan, provide, develop and sustain interprofessional health care in your work environment.
Registered Nurses of Ontario ( 2013) Developing and Sustaining Interprofessional Health Care: Tips and Tools for Health-care Teams, Toronto. ON.
Retrieved from: https://rnao.ca/bpg/guidelines/interprofessional-team-work-healthcare
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Les présentes lignes directrices sur les pratiques exemplaires, Développement et maintien des soins de santé interprofessionnels : optimisation des résultats pour le patient/client, l’organisme et le système sont conçues pour favoriser des milieux de travail sains. Les présentes lignes directrices déterminent les pratiques exemplaires pour faciliter, améliorer et maintenir le travail d’équipe ainsi que la collaboration interprofessionnelle, et pour accroître les résultats positifs pour les patients/clients, les systèmes et les organisations.
Association des infirmières et infirmiers autorisés de l’Ontario. (2013). Développement et maintien des soins de santé interprofessionnels : optimisation des résultats pour le patient/client, l’organisme et le système. Toronto, Canada: Autheur. Récupéré: http://rnao.ca/bpg/language/d%C3%A9veloppement-et-maintien-des-soins-de-sant%C3%A9-interprofessionnels-optimisation-des-r%C3%A9sul Ce travail est financé par le Ministère de la Santé et des Soins de longue durée d'Ontario.
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Practice standards are documents that help nurses understand their responsibilities and legal obligations to enable them to make safe, effective and ethical decisions when practising. This practice standard aims to help nurses understand the regulatory and legislative requirements for documentation.
College of Nurses of Ontario. (2008). Documentation, Revised 2008. Toronto, ON: Author. Retrieved from http://www.cno.org/globalassets/docs/prac/41001_documentation.pdf
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This learning module reviews documentation and how it is important component of nursing practice and interprofessional documentation that occurs
Reference: College of Nurses of Ontario (2010) Documentation- Learning Module. Retrieved from: https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/learning-modules/documentation-2010/
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This Care Transitions change package provides information that can be used sequentially to complete a specific task (or series of tasks), or can be used selectively and independently, depending on the user’s needs. This package includes an overview of transitions of care, four (4) key evidence-informed change concepts, and a deeper dive into the change concepts.
Reference: Health Quality Ontario (2013) Transitions of Care: Evidence Informed Improvement Package Retrieved September 1, 2016 from: http://www.hqontario.ca/Portals/0/documents/qi/health-links/bp-improve-package-transitions-en.pdf
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This guidelines outline the importance of planning, choice and consent and adults with developmental disabilities receiving appropriate developmental services and supports in a long-term care home. The commitment to developing these guidelines and to following them also demonstrates the integrated and co-ordinated approach to care within and between the developmental services and long-term care home sectors.
Reference: King's Printer for Ontario, 2012 to 24. Retrieved from: https://www.ontario.ca/page/guidelines-supporting-adults-developmental-disability-when-applying-moving-and-residing-long-term-care-home
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This article describes the challenges involved and potential solutions for improving the quality of transitional care.
Reference: Fancott, C. (2011). The Change Foundation. Interventions and measurement tools related to improving the patient experience through transitions in care: A summary of key literature. Retrieved from: http://www.hqontario.ca/Portals/0/modals/qi/en/processmap_pdfs/resources_links/care%20transitions%20literature%20review.pdf
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Cette ligne directrice sur les pratiques exemplaires en soins infirmières et infirmiers est un document détaillé comportant les ressources nécessaires au soutien de la pratique basée sur des données probantes. Un milieu de travail sain, c’est un milieu de pratique qui maximise la santé et le bien-être des infirmières, des résultats de qualité chez le patient ou client, le rendement de l’organisation et du système, et les retombées sociales, y compris des collectivités en meilleure santé.
Association des infirmières et infirmiers autorisés de l’Ontario (2013). Lignes directrices sur le développement et le maintien du leadership infirmier, (2em Ed.). Toronto, ON, Canada: Auteur. Récupérée de http://rnao.ca/bpg/language/lignes-directrices-sur-le-d%C3%A9veloppement-et-le-maintien-du-leadership-infirmier Ce travail est financé par le Ministère de la Santé et Ministère des Soins de longue durée d'Ontario
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Med Rec is a formal process to ensure accurate and comprehensive medication information is communicated consistently across transitions of care. This site provides information that can support medication reconciliation policies and procedures within organizations.
Reference: Institute for Safe Medication Practices (ISMP). (2012). Medication Reconciliation. Retrieved from: https://www.ismp-canada.org/medrec/
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The Medication practice standard describes nurses’ accountabilities when engaging in medication practices, such as administration, dispensing, medication storage, inventory management and disposal.
Reference: College of Nurses of Ontario (2023) CNO Practice Standard-Medication Retrieved from: https://www.cno.org/globalassets/docs/prac/41007_medication.pdf
Copyright © College of Nurses of Ontario, 2023.
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This website contains resources to assist when an individual with dementia is looking at transitioning to long-term care. The Alzheimer Society of Canada webpage has resources to support decision-making.
Reference: Alzheimer Society of Canada (2016), "Alzheimer Society of Canada, Long Term Care”. Retrieved from: https://alzheimer.ca/en/help-support/im-caring-person-living-dementia/long-term-care/moving-long-term-care
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My Transitional Care Plan© (MTCP) summarizes meaningful information that contributes to the facilitation of successful transitions across sectors for older adults presenting with, or at risk of, responsive behaviours/ personal expressions associated with dementia, complex mental health, substance use and/or other neurological conditions.
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My Transitional Care Plan© summarizes information to facilitate successful transitions in care for older adults presenting with, or at risk of, responsive behaviours or complex mental health, substance use or neurological conditions (166). It provides a synopsis of essential information that should be communicated to members of the interprofessional team to prepare and facilitate a transition in care. The tool is written in first person to promote person-centred care, and health and social service providers should collaborate with persons and their support network when completing the form. My Transitional Care Plan© can be built within an electronic health record. The form is also available in French (166).
Registered Nurses' Association of Ontario. (2023). Appendix H of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp 123-124
Source: Reprinted with permission from: Behavioural Supports Ontario (BSO).
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The Patient Oriented Discharge Summary (PODS) is an easy-to-use discharge summary designed for persons transitioning from hospital to home (164). Most traditional discharge summaries are dense documents with technical terms and are designed to communicate information to primary care providers, rather than persons receiving care. PODS was co-created with persons and their support network, including individuals with limited health literacy and language barriers, to help persons understand important information when leaving a hospital. The resource uses plain language, large fonts, space for persons to take notes and is available in 15 languages.
Registered Nurses' Association of Ontario. (2023). Appendix G of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp. 121-122.
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The Patient, Family and Caregiver Declaration of Values was drafted by the Minister’s Patient and Family Advisory Council in consultation with Ontarians to communicate patient, family and caregiver expectations of Ontario’s health-care system (163). The Declaration can serve as a compass for persons and organizations involved in health care and reflects a summary of important person, family and caregiver values. The Patient, Family and Caregiver Declaration of Values for Ontario is also available in French.
Registered Nurses' Association of Ontario. (2023). Appendix F of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp. 120.
Source: Reprinted with permission from: Government of Ontario. Patient family and caregiver declaration of values for Ontario [Internet]. Toronto (ON): Government of Ontario; 2021.
© Queen’s Printer for Ontario, 2021.
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The Code of Conduct (Code) is a practice standard describing the accountabilities all nurses registered in Ontario have to clients, employers, colleagues and the public. It explains what people can expect from nurses. The Code also describes what nurses must do to maintain professionalism, competence and ethical behaviour to deliver safe client care. All nurses (Registered Nurses, Registered Practical Nurses, and Nurse Practitioners) are expected to uphold this practice standard, regardless of their role, title or responsibility.
Retrieved from: https://www.cno.org/globalassets/docs/prac/49040_code-of-conduct.pdf
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This resource lists topics and other Registered Nurses’ Association of Ontario (RNAO) guidelines, and resources from other organizations that align with the Transitions in Care and Services best practice guideline (BPG).
Registered Nurses' Association of Ontario. (2023). Appendix B of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp. 93-94.
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This best practice guideline focuses on collaborative practice between RNs, RPNs and NPs and fostering healthy work environments for these nurses.
Registered Nurses’ Association of Ontario. (2016). Intra-professional collaborative practice among nurses. Toronto, ON, Canada: Author. Retrieved from: https://rnao.ca/sites/rnao-ca/files/bpg/Intra-professional_Collaborative_Practice_042017.pdf
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This nursing best practice guideline will address the therapeutic relationship and its central importance to nursing practice
Registered Nursing Association of Ontario (2002) Establishing Therapeutic Relationships. Toronto, ON Retrieved from Establishing Therapeutic Relationships | Registered Nurses' Association of Ontario (rnao.ca)
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The aim of this guideline is to provide evidence-based recommendations for registered nurses, registered practical nurses and other health-care providers to facilitate client centred learning that promotes and enables clients to take action for their health.
Registered Nurses Association of Ontario ( 2012) Facilitating Client Centred Learning . Toronto. ON Retrieved from Facilitating Client Centred Learning | Registered Nurses' Association of Ontario (rnao.ca)
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The Ontario Primary Care Medication Reconciliation Guide provides quality improvement strategies for implementing, sustaining and measuring medication reconciliation in primary care settings in Ontario (167). A sample medication reconciliation form can be found on pages 43 and 44 of the guide. The Ontario Primary Care Medication Reconciliation Guide is also available in French.
Source: Reprinted with permission from: Institute for Safe Medication Practices (ISMP) Canada, Health Quality Ontario (HQO). Ontario primary care medication reconciliation guide [Internet]. Toronto (ON): ISMP Canada; 2015. Co-published with HQO. Available from: https://www.ismp-canada.org/ download/PrimaryCareMedRecGuide_EN.pdf.
Registered Nurses' Association of Ontario. (2023). Appendix J of Transitions in Care and Services. (Second Ed.). Toronto, ON: Author. pp. 126-127.
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This toolkit offers resources to support the use of SBAR. SBAR offers a simple way to help standardize communication and allows parties to have common expectations related to what is to be communicated and how the communication is structured.
https://www.ihi.org/resources/tools/sbar-tool-situation-background-assessment-recommendation
Reference: Institute for Healthcare Improvement (IHI): ©2023 Institute for Healthcare Improvement. All Rights Reserved.
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The Fixing Long-Term Care Act, 2021 (FLTCA) was proclaimed into force to regulate Ontario's long-term care home sector.
The Long-Term Care Homes Act, 2007 (LTCHA) was revoked, which means it is no longer in force. The new Act also includes a new regulation.Government of Ontario (2021) Fixing Long-Term Care Act, 2021. Toronto ( ON) retrieved from Fixing Long-Term Care Act, 2021, S.O. 2021, c. 39, Sched. 1 (ontario.ca)
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This PSHSA Fast Fact is intended to provide workplace parties with information that can help improve transition of care practices. Improving transitions in care results in improved employee and client safety.
Retrieved from: http://www.pshsa.ca/products/transition-of -care-fast-fact/
Reference: PSHSA - Public Services Health and Safety Association © 2025
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Public Services Health & Safety Association (PSHSA) web tutorial describes the transition of care process, challenges and opportunities to improve practice when supporting those going through a healthcare transition of care.
PSHSA - Public Services Health and Safety Association © 2024.Retrieved from: https://www.pshsa.ca/transition-of-care-healthcare-web-tutorial
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This Transition of Patients to Long-Term Care Following a Stroke Canadian Stroke Best Practice Recommendations identify what is required to have a successful transition.
Reference: Canadian Stroke Best Practice Recommendations. Managing Stroke Transitions of Care (July 2016).
Retrieved from: http://www.strokebestpractices.ca/index.php/transitions/transition-of-patients-to-long-term-care-following-a-stroke/
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This CNO document discusses the nurses’ role when working with unregulated care providers.
Reference: College of Nurses of Ontario (2013) Working With Unregulated Care Providers Retrieved from: http://www.cno.org/globalassets/docs/prac/41014_workingucp.pdf