Reporting

Reporting in nursing

By : Imavike1ReportingOral or writtenChange of shiftNurse to nursePromotes continuity Report on client health status, care required for next shift, significant facts, head to toe assessment, pertinent labs, priority needs, treatments, family issues The report should focus on the nursing perspective and should include the following information: Heading of the document Name, date of birth, date of admission, legal status, who is completing the report and the date the report is completed. Content of the document Nursing care the client is currently receiving, including nursing and care plans. Relevant aspects of the patient's condition as observed on the ward, highlight any changes during the time of the admission and, if applicable, making objective comparisons between past and present episodes of caress

SBAR Technique for CommunicationS- SituationB- BackgroundA- AssessmentR- RecommendationEnd of Shift ReportKeep professionalAvoid judgemental languageInclude assistive personnelTelephone ReportsInform physician of changesClient transfers to different unitsResult reports from lab or radiologyClient transfers to different institutionsInfo needed: When call made, to whom, info givenKeep clear, accurate, repeat info if necessaryTelephone OrdersPhysician to RNPhysician must co-sign within 24 hoursNightime, emergency ordersGuidelines and procedure per institutionBe careful, precise and accurate with orderWrite order as said by physician, repeat it backTransfer ReportsUnit to unit reportPhone or in personAll pertinent data about patientSend all belongings with clientReview clothing/belonging list prior to transferTransfer Sheet DocumentationIncident ReportsAny event not considered routine (falls, needlesticks, med errors, accidental omissions, visitor injury)Risk Management will analyze trendsChanges in policy/procedure, educational programs may be related to findingsNotify supervisor, physician of incidentNurse who witnesses makes out reportDo not assign blame, be objective, facts onlyTips for DocumentationAccurate, timely, thorough, factual, neatUse only approved abbreviations & termsBlue or black inkAlways get and give reportFocus on a team approachDate, time each entry, do not block chartDocument in a timely fashionFollow the nursing processUse appropriate forms

Documentation TipsCorrect errors promptly, using proper techniqueWrite on every line, leave no spacesSign each entry with full signature and correct titleFollow institution policy and procedure for chartingExample of shift report: RN to RNThe purpose of shift report is to communicate patient care issues to the following shift.

Cont..The following elements should be included during shift report: Patient Name, room number, age and admission dateDiagnosis Code statusIsolation precautionsRestraint or 1:1/Constant Observation order and date of current orderFocused patient historyAbnormal vital signsIf on telemetry, most current rhythmUntoward events that occurred during the shiftPlan of care for the on-coming shift (Scheduled tests/procedures, pending lab work, follow up consents, orders, etc)Abnormal lab or diagnostic test results Discharge/transfer information Cont..Estimated time of Report = 1 minute/patient Report begins PROMPTLY at the beginning of a shift Additional patient information is available from other sources on the unit(DO NOT INCLUDE IN VERBAL REPORT): Complete past medical history/course of hospital stay Medications Treatments/wound care Diet Social history

NOTE: If the RN/LPN is delayed/late or a staff member is being floated to a unit and may be arriving late and the charge nurse has been notified of the delay, the charge nurse will obtain report for the incoming RN/LPN after first obtaining his/her own shift report. The charge nurse will communicate this information to the incoming RN/LPN upon arrival to the unit

Bedside reportFactors promoting bedside report:Improved communication between nursesPatient involvement in handoverImproved patient safety and careFactors opposing bedside reportLack of confidentialityMay take more time for reportNurses in a routine and dont want to changeNurses uncomfortable doing report in front of patients

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