Several factors go into caring for patients, especially those who are overcoming serious illnesses or recovering from surgery. These patients often require extended care and treatment from a number of different nurses. Because understanding the personal needs of individual patients is a vital part of providing proper care, it’s important that each nurse is provided with a detailed end-of-shift report at the beginning of each new shift.
Importance of the End-of-Shift Report
A proper end-of-shift report is a compilation of details recorded by a patient’s nurse. Written by nurses who are wrapping up their shifts and provided to those nurses beginning the next shift, these details should include a patient’s current medical status, along with his or her 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. Without these details, a nurse could potentially endanger a patient’s life.
The different needs of individual patients are best met when the nursing staff understands their current medical situations. An end-of-shift report allows nurses to understand where their patients stand in regard to recovery by providing a picture of a patient’s improvement or decline over the last several hours. By knowing what has previously occurred in a patient’s treatment plan, nurses can proceed with the right steps to contribute to positive outcomes.
Tips for an Effective End-of-Shift Report
When making an end-of-shift report, there are several key things nurses must keep in mind aside from just including a patient’s necessary medical information. The following are ways you can create more thorough and adequate end-of-shift reports for your relieving nurses.
Use Concise and Specific Language
When writing your end-of-shift report, avoid vague language that may confuse the next nurse. Instead, help the incoming nurse focus on the task at hand by describing your patient’s status with specific, straightforward vocabulary. Also, provide concrete data gleaned from your personal observations, as well as the results of any and all procedures performed during your shift.
Every notable detail of a patient’s status, regardless of how minute, may prove to be vital during the course of recovery. It’s important to fill your end-of-shift report with every piece of relevant information that relates to your patient’s condition. Omitting an item that may seem unimportant could lead to disaster if it’s not communicated to the incoming nurse.
Conduct Bedside Reporting as Often as Possible
Reviewing the end-of-shift report directly with the patient, his or her accompanying family members and the incoming nurse is often referred to by medical staff as bedside reporting. When possible, bedside reporting is typically the first thing done as a nurse arrives for a shift. This conversation provides the opportunity for all parties to ask any questions they may have before getting to work, and it also allows the patient to be actively involved in his or her own care.
Reserve Time to Answer Questions
Even when bedside reporting is not done before each shift, many nurses have questions regarding the end-of-shift report. It’s important to optimize the time the next nurse and the patient spend together to ensure their questions get answered and that all details of the end-of-shift report are clarified. When it comes to taking the next steps in caring for a patient, nurses are more likely to be effective when they’ve had all of their concerns addressed.
A patient’s condition can change drastically and may require immediate attention. In some cases, especially when working with patients in the intensive care unit (ICU), specific care orders may be placed by a head nurse or supervising physician, and it’s vital that each nurse fully understands them. To ensure a patient receives the proper care, nurses should include special orders on each end-of-shift report and take time to review them directly with the incoming nurse.
Keep yourself and the incoming nurse organized with a well-constructed systematized end-of-shift report. Organizing details and addressing information clearly within your report can help in providing the right information quickly during critical situations.
Formatting Your End-of-Shift Report
With all the necessary information to include, the task of writing an end-of-shift report that’s clear and easy to read can be a challenge. Consider the following two formats to help you stay organized and communicate the right information in a concise and professional manner.
The PACE Format
This format involves a straightforward organizational technique. PACE is an acronym standing for Patient, Actions, Changes and Evaluation, all of which serve as sections in the report.
• Patient: List all of the patient’s personal information, including age, medical history details, current condition and latest symptoms.
• Actions: Include a step-by-step account of the facility’s treatment plan.
• Changes: Detail the patient’s ongoing needs and list all actions the incoming nurse should take during his or her shift.
• Evaluation: Provide notes on the patient’s reaction to treatment, along with any other important observations you make during your shift.
Head to Toe
A popular method for formatting end-of-shift reports, this technique provides a convenient road map for incoming nurses. Incorporate this method into your reports to cover all patient details from most important to least, including condition, progress, specific needs and any instructions for following orders. Not only does this method allow incoming nurses to easily pinpoint details in critical situations, but it will also provide you with a simple, step-by-step checklist, ensuring you provide all the necessary details.
Improve Your End-of-Shift Reports and Your Nursing Career at NDMU
When it comes to creating proper end-of-shift reports, it’s important to put forth your best effort. Apply the same dedication to your nursing career with NDMU’s fully online RN to BSN degree program.
NDMU understands that working RNs lead busy lives, which is why this online program allows you to complete coursework on your own time, from anywhere your busy schedule takes you. Excel in your studies with help from experienced educators, online tutoring opportunities and an extensive eLibrary. Contact an enrollment counselor today to unlock your nursing potential.