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How to Give a Solid Nursing Report

Are well-developed nursing reports a dying art form? With ongoing staffing shortages and increasing patient loads, nurses may be too exhausted to think clearly at the end of a shift. It can be easy to dismiss reporting as one more trivial task and rush through patient information for the sake of making it to the time clock. 

When there is a gap in communication around patient details during nursing handoff, patients are put at risk for potential harm. Nurses spend their whole shift keeping patients out of harm’s way, so why not take one last safety measure?

Giving a solid nursing report to ensure that accurate health information is passed along, and requires your attention, no matter how much of a whirlwind your shift was. During nursing handoff, it’s important to have a big-picture understanding of the patient’s condition, from the events that led up to their hospitalization to what their recovery will look like. There are a few tricks and processes to help you deliver a strong nursing report with confidence and clarity. 

Get to Know Your Patient from the Start 

Just like nurses prepare patients for discharge from the time of admission, you can prepare yourself for handoff from the beginning of your shift. To do this, collect a detailed account of patient history when taking report. You want to start developing a holistic understanding of your patient’s condition early, so gather as much background information as feasible during handoff.

 Always be confident speaking up and asking questions if you feel like a detail is missing! The better you know your patient from the beginning of the shift, the more your care will make sense. When the end of your shift comes around, you will be able to effectively explain why you provided those treatments and interventions to the oncoming nurse.

Practice Report an Hour Early

About an hour before your shift is over, take a few minutes to review your report sheet and practice what you are going to say during nursing handoff. If you have not had a chance to review your patient’s history, this is the time to collect information from the chart to ensure that you are passing along accurate information. Additionally, update numerical data like intake & output and lab values that will be helpful for the oncoming nurse to know.

Pro tip: When med students or specialty providers come to you for an update, use this as an opportunity to practice handoff as you recount the events of your shift. 

Follow a Systematic Approach 

When the time comes to give your nursing report, the best way to stay confident and keep yourself on track is by following a systematic approach. Start by using the SBAR format (Situation, Background, Assessment, Recommendation) and transition into a head-to-toe review of symptoms within the assessment section.

During the “situation” section, provide a one-liner about the patient and why they are in the hospital. This is where you should include details such as weight, code status, and any isolation precautions. Next, share a background of your patient’s health history, including past hospitalizations or surgeries that are or could be relevant to their current illness. 

When you review your nursing assessment, always follow a head-to-toe order. Begin with the neurological system and work your way to the cardiac, respiratory, gastrointestinal/genitourinary, integumentary, and psychosocial systems. After reviewing the details in each section, discuss the patient’s IV access and which fluids or drips are running through each line. 

To finish up, discuss the plan for the upcoming shift. What labs will the oncoming nurse be responsible for collecting? Is the patient going off-unit for any procedures? Provide the oncoming nurse with a clear picture of what the patient’s shift will look like. 

A nursing report doesn’t need to take all day, but a systematic approach is key to delivering an efficient and effective handoff. A solid nursing report will leave you feeling proud of the care you provided — and your patients and colleagues might just thank you too.

alexadavidson
Alexa Davidson

Alexa is a registered nurse and freelance health writer. She began her nursing career in adult surgical trauma then spent 10 years in neonatal and pediatric cardiac intensive care units before working as a travel nurse. After earning a master’s in nursing education, Alexa began teaching associate degree nursing students. Alexa is focused on writing approachable content that empowers women to take control of their reproductive health. Her work is featured on blogs including the Inito fertility app, S’moo hormone balance supplements and various healthcare facilities. Visit thearticulatern.com to learn more about the population Alexa is serving as a nurse writer.

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Great informational piece

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