a nurse is recording an end-of-shift report for a patient. what information needs to be included?

by Mr. Reuben Flatley 9 min read

How to Perfect Your End of Shift Report | NDMU Online

4 hours ago 1551 Words7 Pages. Nursing handover also known as end-of-shift report is a complex and patient specific process that involves transferring patients’ information and plan of care to … >> Go To The Portal


When a nurse finishes their shift, they take a few minutes to record the patient's status so that the next nurse has all a patient's information when they take over their care. The report includes items such as the patient's name, current medications, allergies, general medical history, pain levels and discharge information, if needed.

Full Answer

Why is it important for nurses to provide end-of-shift reports?

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.

How do you write an end of shift report for nurses?

Tips for an Effective End-of-Shift Report 1 Use Concise and Specific Language. When writing your end-of-shift report, avoid vague language that may confuse the next nurse. ... 2 Record Everything. ... 3 Conduct Bedside Reporting as Often as Possible. ... 4 Reserve Time to Answer Questions. ... 5 Review Orders. ... 6 Prioritize Organization. ...

What is a nursing report?

Nursing report is given at the end of the nurses shift to another nurse that will be taking over care for that particular patient. Nursing report is usually given in a location where other people can not hear due to patient privacy.

What is the pace format for nursing shift reports?

While some nurses devise their own nursing shift report formats or use a format provided by their workplace, others use a standardized format for their nursing shift reports. The PACE format gives you a straightforward way to organize your information.

What is an end-of-shift report?

An end-of-shift report is a detailed report of a patient's current medical status while under your care as a nurse. When a nurse finishes their shift, they take a few minutes to record the patient's status so that the next nurse has all a patient's information when they take over their care.

Why is the end-of-shift report important?

An end-of-shift report is important because it helps the incoming nurse understand how to best care for their patients. They can quickly review a patient's medical history, allergies and the best course of action to take in case of an emergency. In addition, an end-of-shift report allows for a smooth transition from one nurse to the next.

Elements of an end-of-shift report

Different facilities include various components in their end-of-shift reports. Here are some of the typical elements found in an end-of-shift report:

How to create an end-of-shift report

Consider using this list when completing and explaining your end-of-shift report to the nurse taking over the next shift:

Why is it important to get a nursing report before you start your shift?

It is not only important for the nurse but for the patient as well. Nursing report is given at the end of the nurses shift to another nurse that will be taking over care for that particular patient.

Why do nurses give reports outside of the room?

If you are required to give report outside of a patient’s room try to keep your voice down so other patients and family members can not hear. Most nurses use the SBAR tool as a guide to help them give report, which is highly recommended.

What does SBAR stand for in nursing?

SBAR stands for S ituation, B ackground, A ssessment, and R ecommendation.

What is shift report?

The purpose of this assignment is to analyze the effectiveness of the change-of-shift-report at bedside and the implementation of evidence-based practice for an accurate and relevant report.

What is bedside shift report?

Bedside shift reports is a critical process in patient care that can improve patient safety, and reduce errors as a consequence of communication gaps during the transfer of information at the end of each shift. This assignment addressed the problem, and the evidence-based change to practice as with the standardized protocol for bedside-shift-report. We based our conclusion on two studies Translating an Evidence-Based Protocol for Nurse-to-Nurse Shift Report (Dufault et al., 2012), and Bedside Shift Reports: What Does the Evidence Say? By (Gregory, Tan, Tilrico, Edwardson, & Gamm, 2014). After analyzing the data and evaluating the change proposed, we mention the most relevant results concerning to this change.

What does an oncoming nurse do?

The oncoming nurse will review assignment sheet and read information on the computerized reports. At the time of meeting with the off-going nurse, it is necessary to review the information and to add what is not on the computerized report.

What is Press Ganey's Patient Satisfaction Survey?

Press Ganey Patient Satisfaction Survey data (Press Ganey, 2015.) was used to evaluate patient preference and nursing staff competence. It described the patient-centered, evidence-based, best practice protocol developed for the hospital, it made eight recommendations. The study evaluates the information content of the bedside-shift-report in a medium sized magnet-designated community hospital. It serves a high population of tourists, the military and older adults from the surrounding community. This population is similar in the percent of minorities, gender, and socioeconomic status to others community hospitals in the state. Bedside reports have been supported by improving patient safety, patient-centered care, and nurse communication as well as reduce medical errors by the Joint Commission’s National Patient Safety Goals (The Joint Commission, 2015).

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.
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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.
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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 BSNdegree 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 …
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What Is An End-Of-Shift Report?

  • An end-of-shift report is a detailed report of a patient's current medical status while under your care as a nurse. When a nurse finishes their shift, they take a few minutes to record the patient's status so that the next nurse has all a patient's information when they take over their care. The report includes items such as the patient's name, cur...
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Why Is The End-Of-Shift Report Important?

  • An end-of-shift report is important because it helps the incoming nurse understand how to best care for their patients. They can quickly review a patient's medical history, allergies and the best course of action to take in case of an emergency. In addition, an end-of-shift report allows for a smooth transition from one nurse to the next. Here are a few reasons end-of-shift reports are im…
See more on indeed.com

Elements of An End-Of-Shift Report

  • Different facilities include various components in their end-of-shift reports. Here are some of the typical elements found in an end-of-shift report: 1. Details of employee:It is important for the report to include employee details for record-keeping purposes. This may include your name, employee number and the department where you work. 2. Patient information:Include basic info…
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How to Create An End-Of-Shift Report

  • Consider using this list when completing and explaining your end-of-shift report to the nurse taking over the next shift:
See more on indeed.com