When going into nursing, there are countless duties and responsibilities you will have to consider while on the job. For those just getting into the nursing scene or are interested in picking up jobs in healthcare, the idea of giving a shift report may be a new concept. However, one of the most critical things while working in healthcare is giving an accurate end-of-shift report to ensure a smooth and efficient handoff to the next scheduled nurse. Not only does this ensure the continuity of care, but it also keeps the patient informed on who will be providing them care and what the plans are for the next shift. Whether you are a new nurse or a long-time veteran nurse, these tips are sure to help you empower your end-of-shift reports.
Nursing Tips for Shift Report
There are numerous types of nursing reports, some more beneficial than others. After all, there are myriad factors to keep track of, such as nurse shift changes, patient checks, patient status, laboratory orders, and other changes in patient status and nursing documentation. When preparing to hand off your shift to the next nurse, it's important to properly prepare all of the details of your shift and any changes in patient status that happened during your shift. Presentation and clarification are incredibly crucial here because the facts must be presented clearly without leaving any details out. The more that is correctly documented and communicated, the better the next nurse's shift will go, and better patient outcomes will be achieved.
What is an End-of-Shift Report, and Why is it Important?
What exactly is an end-of-shift report in nursing and healthcare, and why is it so important? An end-of-shift report is an organized collection of information gathered by the patient's current nurse and communicated to the oncoming nurse taking over the patient's care.
Details must be written, clear, and concise. Shift reports must include the current medical status, history, patient needs, allergies, a record of the patient's pain levels, a management plan, and any discharge instructions, if necessary.
This report may include a myriad of other items depending on the setting, and it is critical to your job as it provides a clear plan and instructions for the oncoming nurse you are handing off your shift to. These reports allow information to be communicated easily with fewer miscommunications or misunderstandings.
Why Are End-of-Shift Reports Important?
These provide a clear picture of a patient's current medical state, along with any improvements or deterioration that may have happened during the previous shift. Without this information being properly forwarded to the next nurse, it leaves room for mistakes to happen on the job, which can result in patient injury or deterioration. Providing certain treatments to a patient without the proper knowledge can even be life-threatening. Thus, why these reports are so crucial to those you are caring for, yourself, and your fellow co-workers.
Professional Handoff Nursing Tips for Nurses New and Old
When preparing to do your end-of-shift report and handoff to the next nurse in charge, be sure to keep all the information you've learned so far in mind, as well as these next critical factors in how to give a proper handoff report.
Most importantly, you should be sure to maintain proper organization with all of the information you have, keeping your handoff report in mind throughout your entire shift. Be sure to write down all of the necessary information for your handoff and keep any other facts in mind and make notes of them on paper if necessary to verbally report them to the next nurse in charge, such as vital signs, intake, and output, medication administration times, tests, procedures, lab results, etc. In addition to organizing and reporting all the necessary details you have in mind, you should be prepared for any inquiries or questions from the nurse you are handing them off to.
Go into your work with a clear and confident mind and ensure that you are leaving your shift with your patient feel at ease and that the next nurse on duty will also properly care for their needs. Lastly, always remember to keep in mind other tips you have learned about nursing while on duty to do a shift report and introduce yourself to the patient when you come on and report off to the patient when you leave.
Should Nurses Do Rounds with Doctors?
Unlike the other nurses who are actively taking shifts to care for patients in your handoffs, doctors and other healthcare professionals are not always at the bedside of the patient, resulting in countless pieces of information being missed, which can sometimes be critical to each and every individual working to care for said patients. So, does this mean that, along with your fellow nurses, you should be doing rounds with doctors?
Absolutely - when at all possible! It may seem unimportant as it isn't required by your job to do this. However, it is, in fact, more important than one might imagine it to be. You may catch things the doctor communicated with the patient that might not be clear at a later time or other pieces of information you would only find by reading the doctor's notes, or that might be left out entirely! So when possible, enter your patient's room when the doctors do, and help spot your fellow nurses if they are available while the doctors are on the floors. It's another good idea to have a list of potential orders you might need so that you can request them while the attending physician or specialist is there.
