Filling out a nursing shift change report is a foundational skill that any nurse must develop. Effective reporting benefits the entire team, and ensures a smooth and seamless care process. Creating the best reports requires a combination of communication, collaboration, and attention to detail that is essential to the healthcare profession. Whether you are a newcomer or a veteran looking to improve your process, this guide will go over everything you need to know about nursing shift change reports.
What is a nursing shift change report?
Healthcare is a collaborative effort between numerous healthcare providers (HCPs.) When an HCP’s shift ends, another one takes on their tasks. Healthcare is provided round the clock, and there is little time for a comprehensive primer. Quick nursing shift change reports are done to facilitate a seamless transition between the incoming and outgoing nurse.
In it, HCPs write down any changes in patient condition, crucial patient information, care status, and current orders from supervisors or physicians. Filling out a nursing shift report ensures that while two HCPs oversee the same patient, they are always on the same page. It may seem basic, but filing out your nurse change report allows the care process to remain seamless, even as HCPs rotate in and out of the patient room.
What kind of information is on a nursing shift change report?
HCPs are expected to provide numerous details, related to patients and their conditions. This includes, but is not limited to:
- Name and age of patient
- Current medication plans (dosage, what medications they are taking, when they take them, etc.)
- Care services received (diagnostic tests, IV drips, etc.)
- Short overview of medical history
- Recent changes in medical condition
- Why they were admitted to the hospital
- Dietary restrictions
Luckily, many facilities provide a universal format for reports, which specify what information is needed and how the report itself is structured. The kind of information you will be asked to provide will also depend on the status of your patient, the department you work on, the nature of their care plans and more.
How are nursing shift change reports given?
Some reports are given face-to-face at the bedside, or verbally at the nurse’s station. Sometimes, there are blended reports that are split between bedside and nurse station portions. There are even reports that are entirely written.
These reports are typically carried out in the overlap between HCP checking out and the one checking in. They are usually done in 30 minutes, although the allotted time for the report as well as the format is determined by your department. In general, how a report is carried out will depend on the unit, the facility, and even the team themselves.
How can I improve my nursing shift change reports?
It cannot be understated just how important it is for HCPs to work on their reporting abilities. With proper communication, healthcare providers can exchange crucial information and responsibilities without any confusion or unnecessary delays. To report effectively, HCPs need to consider the following:
- Write things down during your shift
It is hard to recount what happened in eight to twelve hours, thirty minutes before you check out. For effective reporting, document important information throughout your shift. By the time you make your report, you have notes that you can draw from. This makes creating a comprehensive report that much easier.
- Create reports with objectivity
You cannot let your subjective thoughts on a patient and their status color the content and tone of your report. Instead, write about their status, information, and current needs as professionally and objectively as possible. Put in the exact dosage and times for their medication plan, the diagnostic tests that were run on them, their current medical status, and more. The incoming HCP needs to work off established facts, to provide the best possible care services.
- Open the floor for questions
You want to make sure there is no room for confusion. As much as you can, accommodate any questions that your fellow HCP may have. You can even ask if they have any questions periodically and/or near the end of your report. The incoming HCP must be completely caught up with what they must do, and what they must know to provide the best possible care services.
- Make your patient involved with the process
In some ways, your patient knows their status better than you do. Only they know how much pain they are experiencing or if they are experiencing symptoms that are harder to trace, with the naked eye. Conduct the bedside report in their presence and periodically ask them about their condition, for more clarity. In doing so, you also make the patient feel respected and heard.