How to Give Report

Tips on how to give report to an oncoming nurse

Critical Care areas use bedside rounding for report.  Medical/Surgical and other areas can give a verbal report or leave a taping of some kind. (Facility specific)

Use an organized format (SBAR) for delivering the report that includes a description of patient's needs and concerns. For each patient, the following information may be included:

Situation:

Background:

Provide a brief history of the stay. Especially include previous falls and past Braden scale.

Assessment data:

  1. Provide objective observations and measurements made during shift. Describe patient's condition, and emphasize any recent changes. Include fall risk and Braden scale and any preventive measures in place.  Describe any fall injuries and pressure ulcers including interventions.  Include any relevant information reported by patient, family, or health care team members, such as laboratory data and diagnostic test results.
  2. Describe therapies or treatments administered during shift and expected outcomes (e.g., relief of pain, improved airway patency). Specify how interventions are uniquely implemented for this patient. Explain patient's response and whether expected outcomes have been met.
  3. Format for evaluation could be a mechanism for reporting on patient's progress and variance documentation.
  4. Describe instructions given in teaching plan and patient's ability to demonstrate learning.
  5. Report on family visitation or involvement, specifically as it influenced patient. Indicate whether family members were included in care procedures or instruction.

Recommendations:

  1. Explain clearly the priorities to which oncoming nurse must attend. Patient's progress toward discharge should be reviewed. Discharge plan identifies interventions and outcomes needed to allow patient to have a smooth transition from hospital or health care facility to home. This plan also identifies health care referrals, roles, and responsibilities of multidisciplinary team, and patient's schedule for follow-up visits.
  2. Current priorities: 
  3. Clarify: Ask staff from oncoming shift if they have any questions regarding information reported. Do not leave until this has been done.
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