How do I write a good shift report?
How do you write the end of a shift report?
Give a Bedside Report. “Check pertinent things together such as skin, neuro, pulses, etc. Be Specific, Concise and Clear. “Stay on point with the 'need to know' information. When in Doubt, Ask for Clarification. Record Everything. Be Positive!
What should a handoff report include?
Nurses complete their handoff report with evaluations of the patient's response to nursing and medical interventions, the effectiveness of the patient-care plan, and the goals and outcomes for the patient. This category also includes evaluation of the patient's response to care, such as progress toward goals.
Change-of-shift report is the time when responsibility and accountability for the care of a patient is transferred from one nurse to another. The communication that ensues during this process is linked to both patient safety and continuity of care giving.
Nurse bedside shift report, or handoff, has been defined in the literature as a process of exchanging vital patient information, responsibility, and accountability between the off-going and oncoming nurses in an effort to ensure safe continuity of care and the delivery of best clinical practices.
It should include the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
Handoff is not a comprehensive communication of every detail of the patient's history or clinical course. Avoid passing on all possible information in an effort to be comprehensive. Too much data may mask or bury the important nuggets that the next provider needs. Don't list every medication the patient is on.
Recommendation: This covers cultural and communication needs, all pending orders, goals for the patient, and plan of care. Allow time for questions from oncoming nurse and patient.
What Is an End of Shift Report? End of shift report is a document employed in a wide range of business organizations and institutions to highlight an employee's turnover from the time he/she assumed responsibility up to the closing time.