REPORTING

By:Mr. M. Shivananda Reddy

Report• A report is oral, written, or computer-based

communication intended to convey information to others.

• The purpose of reporting is to communicate specific information to a person or group of people.

• A report, whether oral or written, should be concise, including pertinent information but no extraneous detail

Types of reports:

Reports commonly used by nurses include • Hand off report A.Change of shift report B. Transfer report• Telephone reports• Incident reports

Hand off reports• Hand-off reports happen any time one health

care provider transfers care of a patient to another health care provider.

• The hand off report may be change of shift report or transfer report

• The purpose of hand-off reports is to provide better continuity and individualized care for patients.

• For example, if you find that a patient breathes better in a certain position, you relay that information to the next nurse caring for the patient

Change-of-shift report

Change-of-shift report is given to all nurses on the next shift

• It includes up-to date information about a patient’s condition, required care, treatments, medications, and any recent or anticipated changes.

Transfer report Transfer report is given whenever the patient is

transferred to other health care unit.It can happen between:• Nursing unit-to-nursing unit transfer• Nursing unit to diagnostic area.• Special settings (operating room, emergency

department).• Discharge and inter-facility transfer

• Hand off report can be given face-to-face, in writing, or verbally such as over the telephone or via audio recording

• A sample hand off report format as follows: • Background information (name, age, and medical diagnosis); • Primary health problem; • Unusual occurrences; • Discharge planning issues; • Identification of significant changes in measurable terms

(e.g., Pain scale);• STAT, or prn medications• Care required such as medications that need to be started,• When a dressing needs to be changed next; • Progress with interventions; and family involvement.

Telephone Reports• Health professionals frequently report about a

client by telephone.• A registered nurse makes a telephone report

when significant events or changes in a patient’s condition have occurred.

• Nurses inform primary care providers about a change in a client’s condition; a radiologist reports the results of an x-ray study

• The nurse receiving a telephone report should document the date and time, the name of the person giving the information, and the subject of the information received, and sign the notation.

• For example 16/6/15 10.35 am Mr. Sahoo, laboratory technician, reported by telephone that Mrs. Anjali’s hemoglobin is 6 gm/dl. Sign at the end

• The person receiving the information should repeat it back to the sender to ensure accuracy.

• It is important that the nurse be concise and accurate.• Telephone reports usually include the client’s name

and medical diagnosis, changes in nursing assessment, vital signs , significant laboratory data, and related nursing interventions.

• The nurse should have the client’s chart ready to give the primary care provider any further Information

• After reporting, the nurse should document the date, time, and content of the call

Telephone Orders & Verbal Orders:• A Telephone Order (TO) occurs when a health

care provider gives an order over the phone to a registered nurse.

• A Verbal Order (VO) involves the health care provider giving orders to a nurse while they are standing near each other.

• TOs and VOs usually occur at night or during emergencies and frequently cause medical errors

• ThE NURSE reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct

• The health care provider later verifies the TO or VO legally by signing it within a set time (e.g., 24 hours) as set by hospital policy.

Guidelines for telephone and verbal orders:

• Clearly determine the patient’s name, room number, and diagnosis.

• Repeat any prescribed orders back to the physician or health care provider.

• Use clarification questions to avoid misunderstandings.• Write TO (telephone order) or VO (verbal order), including

date and time, name of patient, the complete order; And sign at the end.

• Follow agency policies; some institutions require telephone orders to be reviewed and signed by two nurses.

• The health care provider must co-sign the order within the time frame required by the institution (usually 24 hours).

Incident or Occurrence Reports• An incident or occurrence is any event that is not

consistent with the routine operation of a health care unit or routine care of a patient.

• Examples of incidents include • Patient falls, • Needlestick injuries, • A visitor having symptoms of illness, • Medication administration errors, • Accidental omission of ordered therapies, and • Circumstances that lead to injury or a risk for patient

injury.

Incident Report• Incident (or occurrence) reports are an important

part of the quality improvement program of a unit.• Always contact the patient’s health care provider

whenever an incident happens• In the incident report form document an objective

description of what happened, what you observed, and the follow-up actions taken.