Reporting change of shift reports Updated on 19/02/19

1. Reporting change of shift reportsUpdated on 19/02/19 Reviewed by: Presented by: Mr. Gireesh Mrs. Prashma Associate Professor Lecturer Dept. of MSN Dept. of MSN

2. Learning objectives • To define report • To list out the and explain the types of reports • To explain the purposes of report.

3. 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 client’s care

5. Report • A report is oral, written, or computer-based communication intended to conveyinformation toothers. • The purpose of reporting is tocommunicate specific information to a person or group of people. • A report, whether oral or written, should be concise, including pertinent information butno extraneousdetail

6. Types ofreports: • Reports commonly used by nursesinclude • Hand offreport • Change of shiftreport • Transferreport • Telephonereports • Incidentreports

7. Hand offreports • Hand-off reports happen any time onehealth care provider transfers care of a patient to another health careprovider. • The hand off report may be change ofshift report or transferreport • Hand off report can be given face-to-face, in writing, or verbally such as over thetelephone or via audiorecording

8. Purposes • To improve patient care • To provide continuity of care among nurses who are caring for a patient For example, if you find that a patient breathes better in a certain position, yourelay that information to the next nurse caring for thepatient • To encourage a more consistent exchange of information • To increase the efficiency of handover.

9. Change-of-shiftreport • Change-of-shift report is given toall nurses on the nextshift • It includes up-to date information abouta • patient’s condition, required care,treatments, medications, and any recent or anticipated changes.

10. Patients handover consist • Client name, age, marital status, religious preferences, physician and family contact • Medical diagnosis • Nursing diagnosis • Allergies • Medical orders: diet, medications, intravenous (IV) therapy, treatments, diagnostic tests and procedures(including dates and results), consultations.

11. Patients handover consist • Activities permitted: functional limitations, assistance needed in activities of daily living and safety precautions

12. Transferreport • Transfer report is given whenever the patientis transferred to other healthcare unit. • It can happenbetween: • Nursing unit-to-nursing unittransfer • Nursing unit to diagnosticarea. • Special settings (operating room,emergency department). • Discharge and inter-facilitytransfer

13. TelephoneReports • Health professionals frequently report abouta client bytelephone. • A registered nurse makes a telephonereport • when significant events or changes in apatient’s condition haveoccurred. • Nurses inform primary care providers abouta change in a client’s condition; a radiologist reports the results of an x-raystudy

14. TelephoneReports • The nurse receiving a telephone report should document the date and time, the name of the person giving the information, and the subjectof the information received, and sign thenotation. • For example 16/6/15 10.35 am Mr. Sahoo, laboratory technician, reported by telephonethat Mrs. Anjali’s hemoglobin is 6 gm/dl. Sign at the end

15. The person receiving the information should repeatit back to the sender toensure accuracy. • Itis importantthatthenursebeconciseandaccurate. • Telephone reports usually include the client’s nameand medical diagnosis, changes in nursing assessment, vital signs , significant laboratory data, and related nursing interventions. • The nurse should have the client’s chart ready togive the primary care provider any furtherInformation • After reporting, the nurse should document thedate, time, and content of thecall

16. Telephone Orders & VerbalOrders: • A Telephone Order (TO) occurs when a health care provider gives an order over the phone toa registerednurse. • A Verbal Order (VO) involves the health care provider giving orders to a nurse while theyare standing near eachother. • TOs and VOs usually occur at night or during emergencies and frequently cause medical errors

17. ThENURSE reads the order back to thehealth care provider, called read back, and receives confirmation from the person who gave the order that itis correct • The health care provider later verifies the TOor VO legally by signing it within a set time (e.g., 24 hours) as set by hospitalpolicy.

18. Guidelines for telephone andverbalorders: • Clearly determine the patient’s name, roomnumber, and diagnosis. • Repeat any prescribed orders back to the physicianor health careprovider. • Use clarification questions to avoidmisunderstandings. • Write TO (telephone order) or VO (verbal order),including dateandtime, nameofpatient,thecompleteorder;And sign at theend. • Follow agency policies; some institutions require telephone orders to be reviewed and signed bytwo nurses. • The health care provider must co-sign the orderwithin the time frame required by the institution (usually 24 hours).

19. Incident or OccurrenceReports • An incident or occurrence is any event that is not consistentwiththeroutineoperationofahealthcare unit or routine care ofa patient. • Examples of incidentsinclude • Patientfalls, • Needlestickinjuries, • A visitor having symptoms ofillness, • Medication administrationerrors, • Accidental omission of ordered therapies,and • Circumstancesthatleadtoinjuryorariskforpatient injury.

20. IncidentReport • Incident (or occurrence) reports are an important partofthequalityimprovementprogramofaunit. • Always contact the patient’s health careprovider whenever an incidenthappens • In the incident report form document an objective description of what happened, what youobserved, and the follow-up actionstaken.

21. Do’s and Don'ts

22. Do’s and Don'ts

23. Do’s and Don'ts

24. Summary Today we discussed about purposes of hair washing, equipments required and procedure of hair washing.

25. Conclusion A change of shift report should not simply be reading documented information. Instead significant information about clients are reviewed

26. Evaluation 1. The health care provider giving orders to a nurse while they are standing near each other is termed as a. Verbal order b. Telephone order c. Emergency order. d. Standing order 2. A report that includes up-to date information about a patient’s condition, required care, treatments is called as a. Telephone report b. Transfer report c. Change-of-shift report d. Occurrence report

27. BIBLIOGRAPHY 1. Lindeman Carol A, Meathie OFCONTEMPORARYNURSING Saunders,1999,Philadelphia, Marylov, FUNDAMENTALS PRACTICE,W.B. . 2.White Lois, BASIC NURSING: FOUNDATIONS OFSKILLS AND CONCEPTS, Delmar, 2002. 3. WWW.Wikipedia.com.