The demands of hospital patients are changing to the extent that adaptive changes in workflow or practice are becoming more evident. This paper presents a set of locally designed paper-based tools that are physical manifestations of responses to change, and that provide suggestions for health information technology design. Fifteen nurses were ‘shadowed’ during their shift handover and during the morning interdisciplinary round. Three paper-based tools with the context and reasons for their use are described as are potential vulnerabilities. Suggestions for improvement are made.
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