Creating a proper end-of-shift report is a crucial part of ensuring patient safety and a smooth transition from the outgoing shift of nurses to the incoming one. While it’s definitely enticing to zip out of work as quickly as possible and skimp on the report, you should understand that this is a critical step to good patient care.
If you want to make sure to cover all your bases during the end-of-shift report, keep reading for a few good strategies to get you on the right track.
Instead of starting immediately with a patient’s history, you should focus on important information that will influence everything that happens next. You should address any allergies present, the code status of the patient, and identify other members of the patient’s medical team, if applicable. All of this information should be provided to the oncoming nurse as a way of ensuring that the patient is safe and that protocols will be followed.
Address the Past
As you create your report, you need to consider the details of the patient’s medical history, even if it’s not necessarily related to the current issue. A good technique for doing this is by going simply from head to toe, noting down any health complaints they have had as you go throughout the body.
Note Down Abnormalities
Once you’ve addressed the patient’s health history, it’s a good time to notify the oncoming nurse of any recent abnormalities you’ve noticed in the patient during your shift. For example, any wounds or lesions should be indicated, especially what type of dressing is being used and when that dressing was last changed. For other complaints, note down any seemingly related abnormalities. If a patient is admitted for heart failure, keep a note of their breathing and put that in your report, especially if there are any inexplicable changes.
In your report, make sure to indicate what medications the patient is receiving, how much of it, and how it is introduced. Be clear and specific and don’t forget to include the times of the last dose. Be especially detailed if there is a fluid infusion by indicating what liter is hanging.
Discuss Pain Management
If the patient has complaints of extreme pain or has undergone a procedure that will likely lead to pain, address this in your report. Note down what has been tried, what has been effective, and what hasn’t helped to quell the pain. Don’t forget to write down the time of the last dose to avoid giving the patient too much analgesic.
Discuss the Course of Stay
Give the oncoming nurse a heads up on the future of the patient by giving information about what is next to come in their treatment. If they are scheduled for any tests for X-rays or MRIs, write this down and include when the test is to be done. Likewise, if the patient has had any tests already taken and is waiting on the results, let the next nurse know that results are expected soon. Anything that the patient is scheduled for, including operations, should be included here.This will make sure the oncoming nurse is up to date with what is to come in the future for the patient.
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Address Social Issues
Occasionally, specific social issues will affect the treatment of a patient. Anything out of the ordinary should be identified so the next nurse can proceed with caution, awareness, and tact. These kinds of issues could be homelessness, transportation issues, lack of home support, or a history of drug abuse. These issues need to be relayed to the oncoming nurse so that they can take steps to help provide assistance to the patient upon discharge.
Speaking of discharge, your end-of-shift report is the perfect place to start discharge planning. If the patient is healing well and is likely to be ready for discharge during the next shift, the oncoming nurse will want to know this, as it will affect how she proceeds with care and her own reports.