Nurses must care for patients 24 hours a day, yet no one works a 24-hour shift. In order to ensure the patient’s safety and promote excellent care, communication between shifts is of paramount importance. Yet few nurses learn how to give report in a manner that ensures the transfer of critical information. Here’s how to make your shift report complete, accurate and excellent.
Styles of Report
There are several different styles of nursing report. In one, the team leader or manager collects information from the nurses caring for a group of patients and gives a verbal report to the entire oncoming nursing team. In another, individual nurses report to the nurse who is following them on the next shift. Sometimes reports are taped and at other times they are live verbal reports. A final method of giving a report is the bedside report. This is usually given by the nurse going off shift to the oncoming nurse. Of all these methods, the least desirable is the taped report, as there is no opportunity to ask and answer questions. This is particularly true when the oncoming nurse has never cared for the patient before and knows nothing of his or her history. The bedside report, however, can be the best of the lot.
Key Components of Nursing Reports
No matter what style of report your organization uses, there are a number of key components that you should practice to ensure the information transfer is complete. They are:
- Preparation – collect all the relevant data and write it down; do not rely on your memory. Begin this step far enough in advance of the change of shift that you will not be hurried and miss something important. It is often a good idea to take notes for report as you go through the day.
- Presentation – One excellent way to give report is to present it in the form of a head-to-toe assessment. First, give a brief synopsis of the patient’s medical history and day’s events, including such important factors as surgery, diagnostic studies or changes from the previous shift. Next, cover the findings of your assessments and exams for all body systems. Give the current vital signs and any significant changes during the shift, important lab or diagnostic results, and intake and output. Do not rush through the information – speak clearly and concisely, without slang or jargon.
- Cover all issues – make sure you touch on the plan of care, any safety issues, upcoming procedures and patient or family education issues.
- Clarification – When you finish, pause to ask if there are any questions or if anything you said was unclear. Check that you have answered all questions by asking for confirmation.
Benefits of Bedside Reports
The practice of conducting report at the bedside has a number of benefits. First, both nurses have the opportunity to assess the patient and to see the same thing at the same time. Checking capillary refill, dressings or mental status together, for example, ensures that the oncoming nurse has actual experience to know whether the patient’s condition is changing later in the shift. Bedside rounds also help reassure the patient that the oncoming nurse is aware of any concerns and fully informed about the patient’s status. It offers an opportunity for patients and family members to meet a nurse who is new to them and to ask questions. For the oncoming nurse, bedside report helps with prioritizing the patient’s needs. Finally, there is good evidence to indicate that bedside report decreases falls. It also makes patients and family members feel more involved in care and decisions, promotes teamwork between nurses and shifts, and decreases the potential for errors.
No matter how good a nurse you are, if you can’t give a good report, you are letting your patients and team members down. The communication between shifts can either lead to errors and patient harm or ensure that information transmission protects the patient and improves care. The nurse who follows you may be from a temp agency, or may be returning after several days off. He or she may have never cared for your patient. It’s up to you to provide a complete, accurate picture to your colleague with an amazing report.