*Original post released on 11/9/2022
Change of shift can be an intimidating time for a nursing student or new nurse! This time can be quite chaotic as shifts and staff are changing. Information and updates are hurriedly being given so oncoming nurses can start their shift and off-going nurses can leave. It’s so easy for crucial information to be missed or overlooked. Having a specific routine for taking report can help prevent missing information that could help you throughout your shift, when communicating with colleagues and healthcare professionals, and in the event that your patient’s condition were to change. In this article, I’ll outline crucial information to be collected in a logical sequence.
You can find a great example of a report sheet to help you take a thorough report here. And if you’re just receiving updates, check out this report sheet! And if you’re in L&D, mother-baby, NICU, or postpartum… I also have sheets specifically for you! Check those out here! If you’re in a critical care unit with hemodynamic monitoring, check out these sheets here and here. Lastly, if you like to have a pocket sheet for updates and charting notes throughout your shift, check out this one for ICU or this one for all other units.
So, let’s start off with the basics for information to be collected when getting change of shift report from another nurse! You’ll want to make sure you know your patient’s name, room number or location, age/DOB, gender, allergies, and code status. Along with this info, you should make sure you know when the patient was first admitted to the facility, their admitting diagnosis, any family contacts (or desire to restrict access to their information), and current (and even past) doctors on their case.
Next, you’ll want to dive a little deeper into their situation and gather additional data such as their past medical and surgical history. At this time, you should also be gathering a timeline of events that have occurred since their admission to the facility. These events will typically signify a change in their status that warranted either downgrading or upgrading the level of care, a code situation, procedures, etc. Finally, be sure to inquire with the current nurse about any recent and/or pertinent diagnostic tests as well as their results.
As you continue to move forward in the report process, the next logical step would be to review their current status. This can provide you with some of the most pertinent information about your patient to include their review of systems, current fluids and/or drip medications, any hemodynamic monitoring equipment as well as the patient’s baseline and goal values, their current lines/drains/tubes and IV access, and most recent lab results. When it comes to lines, drains, tubes, and IVs, you should make sure to inquire about their status (patency/functionality), insertion dates, and dressing change dates.
Lastly, take the time to review with the current nurse any pending tasks, labs, studies, procedures, and/or case management needs. Before the current nurse signs off, leaves, and you assume responsibility for the patient, ensure that you review their medication administration record for any pending medications that are due to be given, any electrolytes due to be replaced, and any STAT or overdue orders that need to be addressed. If you aren’t doing bedside report in the patient’s room, make sure you enter the room with that nurse to see your patient, to review their IV medications currently infusing, and to note their overall appearance and status.
When receiving report, don’t forget to make an annotation (if your facility and charting system allow this) of the patient’s current status. Things to include in your quick note include their current vitals, level of consciousness/orientation, medications infusing, side to which they are turned, any pain expressed, position of lines/drains, and oxygenation therapy. You should also make sure to make note of the nurse’s name, title, and the date/time in which you received report for and assumed care of the patient. Doing these things helps to ensure accountability, thorough documentation, and protection of your license in the future should any litigation occur.
I hope this helped ease your mind about receiving report from another nurse while in nursing school or as a new grad nurse! I strongly urge you to consider purchasing a report sheet tool or inquiring with your unit to see if they have a specific report sheet that they utilize. Remember, developing a routine in regards to report will help prevent missing information and allow you to care for your patients in the best way possible.
Until next time, happy studying!