This is Nursing: Shift Report
A guide to giving good basic shift reports for Med Surg/ Tele Nurses. The goal is to give an organized report that paints an adequate clinical picture for the incoming nurse.
Shift report basics
- Name, age, and what brought the patient to the hospital. The first thing a nurse wants to know is the name, age, and what brought the patient to the hospital. This information can be found in the admission/ ED note. What brought the patient to the hospital includes what symptoms the patient was experiencing; was it coffee ground emesis? Rectal bleeding? CHEST PAIN?This also gives the nurse insight into what to look out for during the shift.
- Tests/ scans completed & Specialties involved. This gives insight into patient care, gives you clues on how close the patient is to discharge, and will lead to discussing the current problem with the patient. Use the admission note and the current H&P from the primary physician to read what tests were completed upon admission and throughout the stay. Additionally, state any significant findings from the tests. Next, which specialties are involved in this patient’s care? Nephrology, Cardiology, endocrine, etc. read their notes to view treatment.
- The plan. What are we doing to care for this patient now/ today? Is that patient presenting with anything new? This is your time to mention anything current. For example, does that patient have abnormal heart rhythms or significant lab results? Mention midlines/ central lines, ports, drips, and foleys. Also, if you remember the last time the patient urinated or defecated, make sure you mention that too, especially if it pertains to treatment.
- Ambulatory status, continence, behavioral issues & pertinent health history. Address safety concerns and your experience with the patient. It’s important to highlight anything that may make or break a shift.
Tell a Good Story
Overall, tell a thorough story about the patient from admission to the present time. Try to keep information organized, state the important things, and DON’T take longer than needed. Nurses want to go home! Shift Report is less intimidating the more you practice. Start with nailing the basics! Best wishes and good luck!
-Tayッ
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