nurse report

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I am definitely one of those nurses that replays her shift on the way home from work, while I’m cleaning the grime off of me in the shower, while I’m eating my supper, and then again while I’m lying in bed. What I worry about the most is whether I reported the important information so that the next nurse has a successful shift and the patients are well cared for as a result.

Report plays a huge role in providing quality patient care. I’m definitely still learning the process, but here is what I’ve picked up on so far while working in a transitional care facility.

Report the Basics.

Reporting the basics should be the first part of the report. It gives the nurse a brief picture of the patient that can be built upon during the remainder of the report. Include the admitting diagnosis, pertinent secondary diagnoses, code status, and mental status.

Report the Abnormal.

Is the patient NPO? Is there an abnormal heart rhythm? Elevated temp? How about mobility issues? Hearing or visual deficits? The oncoming nurse will need to know these things.

In order to be thorough and efficient, move in a head-to-toe fashion by body system. After practicing this a few times, you will develop a rhythm and get through this portion of report in less than a minute.

Anticipate What the Oncoming Nurse Will Need to Know.

I am always tempted to tell the oncoming nurse what happened during my shift because it’s what I know, but it’s actually more helpful to the oncoming nurse to keep the focus of report on the anticipated needs of each patient. This may be a little tricky. As an evening shift nurse, you might not be aware of what the night shift looks like on your unit (take the time and ask!).

Here are a few time-sensitive things I find helpful to receive in report before beginning my shift:

  • PRN pain medication schedule
  • Scheduled appointments/procedures
  • Tube feeding/IV completion schedule
  • Blood sugar checks and whether or not the patient takes insulin
  • Patients who haven’t had a bowel movement in three days and what actions have been taken so far (remember, I work in transitional care so patients stay an average of 18 days)

Of course the content of this list will depend on your facility/unit and the shift you are working. Also, the oncoming nurse should never rely solely on report and should consult the MAR before acting on any of these time-sensitive issues. But having this information will help the oncoming nurse anticipate needs, and that’s huge¬†for time management.

Keep it brief.

It’s best to keep report as brief as possible while making sure all of the important info is shared. I hate to put a time limit on report because every unit/scenario is going to be a little different, but I imagine that a 5-10 minute report would be sufficient in most situations.

What do y’all think? What has your experience been with end-of-shift report?

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