Introduction At the end of each shift nurses report information about their assigned clients to nurses working on the next shift. A handover report is usually given orally in person or during rounds at the bedside. Reports given in person or during rounds in hospital permit nurses to obtain immediate feedback when questions are raised about a patient’s/client’s care.
Definition The necessary communication between nursing staff, during shift changeover periods, regarding patient care
Goal To improve patient care - nursing staff will be better informed so can deliver care to a higher standard. To provide continuity of care among nurses who are caring for a client.
To encourage a more consistent exchange of information.
To increase the efficiency of handover.
At the end of a long day of caring for patients, it’s time to give the end-of-shift report to the oncoming nurses. Although it may be tempting to rush through this routine duty, patient safety hinges on a complete and correct exchange of information.
An organized report follows a logical sequence to prepare for the report, the nurse gathers information from work sheets, clients’ records and the clients care plan.
Patients handover consist: Client name, age, marital status, religious preferences, physician and family contact. Medical diagnosis: listed by priority Nursing diagnosis: listed by priority Allergies Medical orders: diet, medications, intravenous(IV) therapy, treatments, diagnostic tests and procedures (including dates and results), consultations, DNR order (when appropriate) Activities permitted: functional limitations, assistance needed in activities of daily living and safety precautions.
A change of shift report should not simply be reading documented information. Instead significant information about clients are reviewed
Example: Background information: Surjit Singh in bed 4, a 60 years client of Dr. _____ is scheduled for Angiography this morning. He had severe Angina. He was admitted last night with chest pain and dysponea. This is first experience with invasive procedure. He knows he may require PTCA according to vessels condition. Assessment:S. Surjit Singh expressed difficulty in falling asleep last night. He had several questions about procedure. Nursing Diagnosis: his chief concerns are anxiety related to inexperience with invasive procedure. Teaching plan: he asks appropriate questions about surgery. Staff on evenings explained postoperative routines. I reinforced information with him early in the night. He stated that he feels less anxious that he knows more what to expect.
Treatments: Tab Sorbitarte sublingual administered and patient put on humidified oxygen. The blood sample had taken and send to laboratory for various examinations. ECG was taken at the time of admission. Allergies: patient don’t have any allergic history. Priority needs: currently, S Surjit Singh is relaxing in bed. The consent form has been signed. All preoperative preparation and checklist have been completed.
Do’s and Dont’s Do’s Dont’s Don’t review all routine care procedures or tasks (e.g. bathing scheduled changes). Don’t review all biographical information already available in written form. Don’t use critical comments about client’s behaviour, such as “Mrs. Gill is so demanding.” Don’t make assumptions about relationships between family members. Don’t engage in idle gossip. Provide only essential background information about client (i.e. name, sex, age physician’s diagnosis, and medical history). Identify client’s nursing diagnosis or health care problems and their related causes. Describe objective measurements or observations about clients condition and response to health problem: emphasize recent changes. Share significant information about family members as it relates to client’s problems. Continuously review ongoing discharge plan (e.g. need for resources, client’s level of preparation to go home)
Do’s Don’t’s Relay to staff significant changes in the way therapies are give (e.g. different position for pain relief, new medication). Describe instructions given in teaching plan and client’s response. Evaluate results of nursing or medical care measures (e.g.’ effect of back rub or analgesic administration). Be clear about priorities to which oncoming staff must attend. Don’t describe basic steps of a procedure. Don’t explain detailed content unless staff members ask clarification. Don’t simply describe results as “good” or “poor”. Be specific. Don’t force oncoming staff to guess what to do first.