How To Give An Excellent End-Of-Shift Nursing Report
Hospitals in the USA are continuing to move away from a unit style handoff report where a charge nurse will briefly talk about each patient with all on-coming nurses, in favor of a bedside handoff report between the off-going and on-coming nurses. The end-of-shift nursing report is an opportunity for the off-going nurse to provide the on-coming nurse with important details regarding a patient's medical history, status, and any upcoming tasks or concerns that need to be addressed. In anticipation of giving an end-of-shift nursing report, I begin writing down the following details 3-4 hours before my shift ends:
Patient Name: Do they have any preferred names or pronouns?
Age:
Weight:
Team/Attending Physician: Which team is following this patient?
Code Status: Is the patient a full or partial code (compressions, intubation, oxygen, medication management, etc.)?
Allergies:
Isolation/Precautions:
Medical History:
Admitting Diagnosis:
Current Problems/Concerns:
Recent Vital Signs:
Line Access/Drains: Does the patient have a PIV or CVL? Is the patient running IV fluids or nutrition? Does the patient have any chest tubes or drains?
Diet Order: Is the patient fed orally or through a feeding tube? Is the patient NPO?
Systems
Neuro: Is the patient alert and oriented? Did they require any PRN medications? Do they have pain?
Cardiovascular: How is the patients perfusion and circulation? Are there any telemetry concerns?
Respiratory: Is the patient on oxygen? Do they have an increased work of breathing?
Gastrointestinal: When was the last bowel movement? Are they tolerating feeds? Did they have any nausea or vomiting?
Genitourinary: Is the patient voiding? How is their urine output?
Musculoskeletal: Can the patient ambulate? Do they need an assistive device?
Integumentary: Are there any wound or incision sites?
Mental Health: Does the patient have any mental health needs? Does the patient or family need to speak to a social worker? Are there any visitor restrictions?
Recent/Upcoming Diagnostic Tests/Labs: Were there any critical lab values that were recently drawn? Are there any upcoming diagnostic tests, labs, or procedures?
Patient/Family Concerns:
As for medications to be given, you can ask the on-coming nurse if they would like to review the medication administration record (MAR) together. Often, the on-coming nurse will have already read through the MAR and may or may not have specific questions related to how the patient takes their medication (e.g. oral versus tube; pill versus liquid). It is common courtesy to inform a nurse if an infusion volume is low and a medication will need to be re-ordered (e.g. a patient-controlled analgesic syringe, heparin infusion, etc.), or if there is an upcoming rate change (e.g. TPN cycling).
It is your responsibility as the off-going nurse to ensure that the on-coming nurse is given all of the relevant information needed to competently and safely care for the patient being handed over. With this style of nursing report, you will ensure that all important details are discussed!
