There are several aspects that go into caring for patients, especially those who are recuperating from major diseases or surgery. These patients frequently require extensive care and therapy from a variety of nurses. Because knowing the unique requirements of individual patients is a key component of delivering adequate care, each nurse should be given a complete end-of-shift report at the start of each new shift.
IMPORTANCE OF THE END-OF-SHIFT REPORT
A correct end-of-shift report is a collection of information gathered by a patient’s nurse. These details should be written down by nurses at the end of their shifts and given to nurses starting the next shift; they should include a patient’s current medical status, medical history, individual medication needs, allergies, a record of the patient’s pain levels, and a pain management plan, as well as any discharge instructions. A nurse may threaten a patient’s life if this information is not provided.
Individual patients’ requirements are best handled when the nursing team is aware of their present medical state. An end-of-shift report provides nurses with a picture of a patient’s improvement or deterioration during the previous few hours, allowing them to understand where their patients are in terms of recovery. Nurses can contribute to excellent results by understanding what has previously transpired in a patient’s treatment plan.
Styles of Reportage
There are various types of nursing reports. In one, the team leader or manager gathers information from the nurses caring for a number of patients and provides a verbal report to the fully arriving nursing team. Individual nurses report to the nurse who will be following them on the next shift. Reports are sometimes taped, and occasionally they are live verbatim reports. The bedside report is the last means of providing a report. This is frequently presented to the approaching nurse by the nurse who is leaving the shift. The taped report is the least desired of these options since there is no chance to ask and take questions. This is especially true if the incoming nurse has never before cared for the patient and knows nothing about his or her past. The bedside report, on the other hand, has the potential to be the finest of the bunch.
5 Tips for Effective Shift Handoffs
- Always Be Geared Up: If you were a scout or knew someone who was, you’ve probably heard this proverb. Many scouts have been rescued because they were prepared, and it will assist you with more efficient shift handoffs. Consider your end-of-shift report in the exact same way as you would a report to the patient’s doctor. Keep in mind that all your facts are conveyed properly.
- Prepare for Inquiries: Place yourself in the shoes of the next nurse and attempt to anticipate their questions. What do you want to know more about patients and the forthcoming shift? Rather than waiting for the next nurse to ask a question, have them repeat it as they understand it. This should clear up any confusion.
- Nursing is a 24-hour job: Remember that your commitment to your patients and coworkers does not cease when the clock strikes midnight. Just like the nurse on the shift before yours assigned your specific duties and tasks, you must do the same for the next nurse. You must be prepared for certain tasks to roll over in order to have more successful shift handoffs. Understand and communicate properly about all duties and action items associated with patient care. It makes no difference if these jobs existed before you came.
- Maintain Organization: While this may sound like “Nursing 101,” it’s astonishing how habits may form. Although there is no right or wrong method to deliver an assessment, certain details may be overlooked if your ideas are disorganized. If the next nurse interrupts you with an unexpected question, you may lose track of your patient’s assessment and needs. When you have to present a lengthy report, there’s a danger you’ll bounce about or go off track, leaving out important material. Try to deliver your handoff reports at the bedside if at all feasible. It is critical to be organized in order to provide more successful shift handoffs.
- Patient Care is a Team Effort: Keep in mind that you are all a part of the team that is giving care to your patient, and that’s the most important thing. Be polite, courteous, and professional. In the following shift, leave your patients feeling confident. Assure them that the next nurse will take good care of them. Make notes instead of relying on your memory. It’s contagious to be optimistic and upbeat! Above all, use concise and clear instructions.
The most efficient shift handoffs occur when the nurse maintains the organization and keeps the handoff report in mind throughout the day. When you follow these five principles, you may practice and enhance your ability to provide efficient shift handoffs. You may also need to work on your communication abilities. Continue to improve your shift handoffs, and you will become well-known throughout the industry.
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Key Nursing Report Components
Whatever report type your firm employs, there are a few critical components you should follow to ensure proper information flow. They are as follows:
- Preparation entails gathering all necessary material and writing it down; do not rely on your recollection. Begin this stage well enough ahead of the shift change so that you are not rushed and miss something vital. It is common practice to take notes for a report throughout the day.
- Presentation – A head-to-toe evaluation is a wonderful method to deliver a report. First, provide a brief summary of the patient’s medical history and the day’s events, noting major aspects such as surgery, diagnostic testing, or changes from the previous shift. Following that, go over the results of your evaluations and tests for each bodily system. Give the current vital signs and any notable changes that occurred throughout the shift, as well as any major lab or diagnostic results, intake, and output. Do not rush through the facts; instead, communicate simply and succinctly, without slang or jargon.
- Cover all issues, including the plan of treatment, any safety concerns, impending operations, and patient or family education.
- Clarification – When you’re through, take a moment to ask if anyone has any questions or if anything that you said was unclear. By asking for confirmation, you can ensure that you’ve actually answered all of the questions.
Benefits of Bedside Reports
The advantages of bedside reporting are numerous, including increased patient engagement and knowledge of care; decreased patient and family anxiety; decreased feelings of “abandonment” at shift changes; increased accountability of nurses; increased team cohesion and relationships among nurses; and decreased potential for mistakes.
Shift change was included in The Joint Commission’s 2009 National Patient Safety Goals, which mandate that shift hand-offs contain up-to-date information regarding the patient’s care, treatment, present status, and recent or projected changes.
Bedside reporting meets The Joint Commission’s Goal 13, a safety approach that emphasizes the patient’s active participation in care.
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