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PROFESSIONAL PRACTICE: How well do you write your nursing report?

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In recent times, I have seen so many nursing reports by colleagues, some shared in various WhatsApp groups and it is quite worrisome. These reports look li ke what anyone could write and you necessarily don’t have to be a nurse to put those together. This has inspired me to pen a thing or two on this.
One striking thing about many of these reports is the obvious lack of professionalism in the first instance of query into the subject matter. A Nursing report that doesn’t reflect Nursing in any way is not a NURSING report. Anyone could write that. In fact, I have seen many other healthcare workers mandating reports these days. Many nursing reports lack nursing diagnosis, nursing actions, and most times, are not written or structured in a professional manner.
Imagine reports like, …. patient slept throughout the night; …..patient met on bed as at resumption time; no complaints throughout the shift; vital signs read thus…..; all patients were duly cared for during the shift and many more…. (All limited to those lines without comprehensive analysis of professional activities).
READ THIS: THE ENEMY WITHIN
I can totally understand that being in the classroom and in practice are two different things but we still need to ensure the standard of nursing practice is not compromised. It is evidently clear that the standard of our nursing reports keep dropping due to many reasons like work overload, absence of enforcement of professionalism, lack of supervision, poor attitude of leaders to quality assurance, traditionalism of practice over evidence based dynamism, the informality of handing over as the standard over documentation and many more. Many nurses are yet to understand that our reports as nurses; reflects who we are and should be meticulously written.

Now, how do we ensure that we uphold the standards in our reports?

  • Apart from medical terms, make use of nursing diagnosis, nursing actions, nursing process in your reports.
  • Seek more knowledge on the use of medical/nursing terms and update self on client assessment.
  • Ensure they are well structured, detailed and free of grammatical blunders and reflect the professional assessment that you have done.
  • For those who are understaffed and over worked, you can employ the use of guidelines/structured nursing report sheets where you can fill in the necessary details. These can be divided into , medical, surgical, post-operative, pre-operative, gynecological cases etc.
  • Depending on the environment, nurses can also think of innovative ways to ensure their nursing reports are always up to the required standard.
  • For nursing leaders, employ the reward and punishment model to motivate nurses in standard report writing. As a nursing leader, you must increase your own knowledge first so that the actions of subordinates can be measured against the standard that you have achieved and corrections can be better put by you.

Henceforth, we should refrain from the uncivilized approach of “patients were duly nursed throughout the shift, slept on duty, or vital signs read thus” “concoction” or should I say memory verse.
Always write reports like the professional that you are!
 

~ Catherine Kuyoro
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25 Responses

  1. Thanks…nicely penned!!! but what prompted me to read was me thinking you’ll give examples of how the reports should be.

    1. Hummmmm! I must commend you on this write up. I was also thinking you were going to give us a comprehensive details on how to also write the reports. Hummmmm! Reports that are being written and are later not being read by the senior colleagues because they come late to work. Some administrative nurses even rewrite the reports but nothing is done for the patient except for the immediate nurse caring for the patient. Let’s be realistic in this country. We have no tangible record. The aspect of Nursing care plan is the most annoying. Most people write and don’t effect on nursing action. What’s the point writing and not doing. Most don’t do what is required of them. I pray for improvement for Nigerian nurses. God bless Nigeria!

  2. I don’t see the need of this write up, if there is no example on what you wrote. Nursing process, nursing actions, nursing diagnosis etc. Write one for us to see. Thanks

    1. I was mandated to peruse through this piece because I thought you would give a sample of what a nursing report should look like. Please rectify this fault.

  3. This post is about using the nursing care plan while nursing individual patients, identify a problem and make a nursing diagnosis, your report should be based on the problem identified and how it was managed during your shift.
    Report on specific things to be looked out for in some patients eg a CVA patient, report on how pressure areas were treated when your at risk diagnosis is made, patient with a wound,give a detailed description of the wound appearance, depth,vascularity etc
    My humble opinion though

    1. After identifying a problem which you indeed did and kudos to you. There should be a solution which we wanted to see an example. Please we are in need of an example.

  4. Thank you for identifying the problems or errors in nursing report writing. Please we needs your examples of patients with different diagnosis. It will help the nurses to understand you more, to learn, emulate and correct themself.
    Thank you.

  5. Am very grateful for you identifying the problems,as you have said earlier,a nursing report should be comprehensive,with diagnosis and your action which should include medical terminologies, please can you give us an example of how do we write nursing report of different conditions.
    Thanks

  6. Thanks for your write up , but I think giving an example will go a long way.you can imagine one nurse managing 40 pts in one ward.How do u expect her to write a comprehensive report on them.Please teach us.

  7. Thanks for the information.
    Can we have an example of a good Nursing report. Choose a Nursing diagnosis and write a report on it.

  8. Thanks so much for your observation on Nurses report. It is embarrassing to see a Nurse’s report on patient that is full of Dr’s clerking and prescription. Nothing to show about your own core nursing activities. More enlightenment should be done on this, to prevent put the profession in to ridicule.

  9. Nice point . But it would be appreciated if sample is given. I expected to see it, but to no avail.
    Thanks and looking forward to that .

  10. Ah! I thought you have a standard or up to date method of writing the nursing report for us to learn?why observed an error if there’s no corrections for it?

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