How to Give an Awesome Report

Hey there nursing students and nurses! In this week’s article, I wanted to flip a previous topic and discuss the alternative side to report… so we’re going to discuss how to give the best change of shift report possible. We’ll cover topics like demographic information, admitting and consulting physicians, medical and surgical history, brief history of admission, diagnostic tests/lab results, and a head to toe assessment among other things. Without further ado, let’s get started!

To start, make sure you’ve grabbed a piece of paper to write down all of your patient’s pertinent information. When beginning to receive change of shift report (or transfer of care report), it is vital to know the name and title of the person giving you information. I typically jot this information down in the lower corner of my paper. Then, you’ll want to make sure you have the patient’s name, age or date of birth, gender, code status and any allergies listed. I usually put this information in the upper left corner of my paper, while I write the room number in the upper or lower right corner of the page. Underneath the patient’s demographic information, I will record the name of the admitting physician and any consulting physicians (and their specialties if unknown to me previously). On a side note, it may be intelligent of you to also make sure to record any family contact names and phone numbers if available just in case an emergency arises. This can be especially helpful when you down or upgrade the patient’s level of care during your shift, need to discuss code status, and/or inform relatives of a change in the patient’s condition. Lastly, still on the left hand side of my paper, I also note all of the patient’s known past medical and surgical history.

Off to the right side of the page, I then record information about the circumstances of the patient’s admission and any events since admission. I’ll begin with noting the date of admission as well as their main complaint at that time and admitting diagnoses. Next, I’ll make sure to note any of the major events that have occurred during the time since their admission. Underneath this info, I’ll record any pertinent diagnostic tests/studies and most recent lab results.

I use the lower left hand side and middle of the page to record my head to toe assessment data from the previous shift. First, I’ll begin with their max temp, especially if they’ve been febrile within the past 12 hours. Next, I move on to the neurological system. Are they alert and oriented? How are their pupils, reflexes, strength? Can they follow commands and ambulate? Then, I record respiratory and cardiac information. Are they using oxygen and if so, what is the method of delivery and concentration? Are they intubated? If so, what are the vent settings and ETT markings? Any chest tubes? What has their heart rate range and rhythm been like? Blood pressure? Any ectopy noted on the ECG if they are being monitored? Do they have an arterial line in place, and if so, where is the insertion site and how does it look? Any drip medications currently infusing? Hemodynamic monitoring equipment, recent parameters, goal parameters?

After these systems, I move on to the genitourinary and gastrointestinal systems. How do they urinate (if they do at all)? Estimated urine output over the past 12 hours? Are they a dialysis patient, and if so, how do they obtain access and which day(s) are they receiving treatment? When was the last dialysis session, and how much fluid, if any, was removed? Any fluid restrictions? Do they have active bowel sounds? Have they had a recent bowel movement; if so, what was the date of the BM? Are they NPO? If not, what is their diet and consistency? Any tube feedings? If so, when was the tubing and feeding solution last changed? Last blood glucose measurement?

Following this, I move on to my integumentary assessment. Are there any alterations in skin integrity, any surgical incisions or wounds, and what is their IV access? Do they have any drains or wound vacuums in place? Finally, off to the lower right hand side of the paper, I record any pending items, case management needs, and general notes to myself.

If you thought this article and its information was helpful, I can assure you that you’ll find my change of shift report sheet download extremely helpful! You can get the link to this report sheet here. Once you’ve downloaded the document, you can print, reprint, and make copies of the report sheet for your own personal use while at work. This document easily lays out all of the information I’ve covered in this article so you don’t have to worry about missing something during report…AND, if you tend to get nervous or get jitters during change of shift or when receiving a new admission, this sheet can really help give you some structure to help reduce these anxieties. I truly hope you’ve found something useful in this week’s article and some proposed questions to consider when obtaining information about your patients that will help you ultimately protect your license. Until next time, happy studying!

Andra Alyse

P.S. If you work in L&D or OB/Peds, I have report sheets designed for you too! Just click on your specialty! I also have a report sheet for updates in case you and your nurse are handing off the same patient for another shift in a row. Check out the updates sheet here.