THEORY AND DISCUSION

NURSING REPORT
1.1 Definition

All profesional persons need to be accuntable for the performance of their duties to
the public. Since nursing has been considered as profession, nurse need to record their
work on completion. Reports can be compiled daily, weekly, monthly, quarterly and
annualy. Report summarize the service of the nurse and or agency. Reports maybe in the
form of an analysis of some aspect of a service. These are based on records and registers
and so it relevant for the nurses to maintain the records regarding their daily case load,
service load and activities.

The report of nursing is the document developed and written by the nurse at
discharge, who has attended the patient during hospitalization. Includes the fundamentals
of nursing process for patient admission, ensures the continuity of care, facilitates the
monitoring of patients and clarifies the role of the nurse in the population it serve.
Another definitation describe it as “the document closes the care process nurse intiated
upon patient admission to a hospital, since communicating information about said patient
between the two levels of support to our existing health care system.
1.2 Importance of Reports
1. Good reports save duplication of effort and eliminate the need for investigation
to learn the facts in a situation
2. Full reports often save embbrasment due to ignorance of situation
3. Patients receive better care when reports are through and give all pertinent data
4. Complete reports give a sense of security which comes from knowing all factors
in the situation
5. It helps in efficients management of the ward
1.3 Type of Nursing Reports
1. Oral reports
Oral report are given when the informationt is for immediate use and not fot
permanency
2. Written reports
Reports are to be writtent when the information tobe used by several personel,
which is more or less of permanent value
1.4 Reports Used In Hospital Setting
1. Change of shift reports or 24 hours report
- Provide only essential background information about client
- Identify clients nursing diagnosis or health care problems and other related
causes
- Describe objective measurements or observtions about client conditions and
response to health proble,s.
2. Transfer reports
A tranfers reports invovle communication of information about clients from
nurse to nurse, to doctor or another medical team.
3. Incident reports
4. Densus report
5. Birth and death report
6. Anecdotal report
1.5 How to do nursing report to doctor
When nurse giving a report, nurse use SBAR method. SBAR is an acronym, which
help nurse stay organized and provide a good a report. Each letter stands for an importants
segmen of infomation that should be included in patients handoff. SBAR method is
communication uses logical tools so that can provide information to others accurately
and efficiently
- Situation
Situation refers to the patients diagnosis and events of their current hospitalization.
During this part of thereport, it is importants to mention the patients vital sign during
your shift. In tihis section of the report, state concisely whom the nurse calling about and
what prompted the call
- Background
The background section of this approach has the most variability built. The component
of report is the patient’s background or past medical history. Althought the patient may
be in the hospital for one ilness, it is helpful to know what othe conditions the have or
had in the past. This type information is critial in giving the doctor a complete clinical
picture of the patient’s condition.
- Assesment
Information the nurse gathered in nurse’s assessment comes next. This includes anything
that stands out during the nurse review of body systems. Dont be afraid to let the doctor
know where the nurse concerns lie
- Recommendation
Recommending a solution to a problem might feel a bit awkaward to a nurse, especially
newer ones, but doctors are often open to collaborations and dont mind working in
tandem with a nurse.

After the nurse giving report to the doctor, doctor can give treatment to the patient and
the nurse continue give nursing treatment to the patient with nursing process. Nursing
process is assessment, diagnosis, outcomes/planning, implementation and evalution.

1.6 Criteria For A Good Report

- Reports should be made promptly if they are to serve their purpose well
- A good report is clear, complete, concise
- If it is written pertinent, identifying data are include the date and time, the
people concerned, the situation, the signature of the person making the report
- It is clearly stated and well organized for easy understanding
- No extraneous material is included
- Good oral reports clearly expressed and presented in an interisting manner,
important points are emphasized
 DAFTAR PUSTAKA

ACT Academy. Online library of quality, service improvement and redesign tools
(diakses pada tanggal 15 september 2018) (https://improvement.nhs.uk.doc)
Brar, Jasleen. Nursing records and reports (diakses pada tanggal 15 september 2018)
(htps://www.slideshare.net/mobile/jasleenbrar03/nursing-records-reports)
Pratiwi, Indah. Book 2 : English For The Professional Nurse. Muhammadiyah
University Of Malang
 PAPER
ENGLISH LANGUAGE (COMMUNICATION)
“NURSING REPORT”

OLEH:

SILMA SAHARA PUTRI 17.321.2762

A11-B
PROGRAM STUDY ILMU KEPERAWATAN
SEKOLAH TINGGI ILMU KESEHATAN WIRAMEDIKA PPNI BALI
TAHUN 2017/2018