Definition of report:
Is one form of orientation, it gives information about the existing
situation.
Process of exchanging vital patient information, responsibility, and
accountability between the off-going and oncoming nurses in an
effort to ensure safe continuity of care and the delivery of best
clinical practices.
Is a detailed record of a patient’s current medical status. It’s written
by nurses who are finishing up their shifts and are then given to
nurses who are beginning their next shifts. It should include the
patient’s medical history, current medication, allergies, pain levels
and pain management plan, and discharge instructions.
Importance of shift report:
1. Good shift report saves duplication of effort and eliminates the need
of investigation to learn the facts in a situation.
2. Full shift report often saves embarrassment due to ignorance of a
situation.
3. Full shift report gives a sense of security which comes from knowing
all factors in the situations.
4. PT received better care when shift report gives all pertaining data.
5. To prepare personal for their daily work according to pt condition.
6. To provide continuity of nursing care.
Types of shift report: (two types of shift report).
1-Oral shift report
Given when the information is immediate use and not for permanency
such as:
Report between nurses.
Report to doctors and supervisors.
In case of changes in assignment.
To nurse who is assigned to pt. care.
Characteristic of good Oral shift report:
Well organized.
Brief notes.
Clearly expressed and presented in an interesting manner.
Important points are emphasized
.2-Written shift report
Is written when the information is to be used by several people or
more or less of permanent value. Include morning, evening and night
reports.
Characteristic of good written shift report:
Clear, complete, concise and objectively.
Well organized.
Include signature of the person who make it.
Identifying data are included, the date, time and people
consumed.
Cases that should be included in the daily shift report:
Admission, discharge, transfer and death cases and excuse cases.
Operation cases scheduled for O.R, prepared for O.R, post-operative
operation is cancelled or postpone)
I.V. cases.
Catheter cases.
Nasogastric tube cases (for feeding or suction)
Dressing cases.
Cases that needed specific observation for their condition for
anticipating complains may occur.
Comatose patients.
Cases that get out unit for any cause as x-ray, physiotherapy.
Cases on monitor or ventilator.
1- Admission Case:
Nurse must write the following:
Time of admission.
Description for the physical mental of pt. condition.
Presence of bed source or other skin disease.
Vital signs of admission.
2- Discharge case:
Include the following information:
Time of discharge.
Physical mental condition of pt. on discharge.
Vital signs, time, place of follow up.
3- Transferred case: (In, Out of the unit)
Include the following information:
Time of transferred
Physical mental condition of pt.
Vital signs, time, place from which the pt. was transferred.
4- Death cases:
Include the following information:
Description for the changes that occur to the pt. condition.
Time of occurrence, to whom it is reported, what had been
done to the pt., how it was treated, types of medication given.
Result of treatment, time of death, signature of the person who
writes the report.
5- Excused cases:
Include the following information:
Time of leaving hospital.
Physical mental condition and vital signs.
Causes.
Time of return, date.
6- Operation cases:
include the following information:
Cases scheduled for O.R (time of scheduled for O.R, vital signs)
Cases prepared for O.R (date, day, time for operation)
Postoperative cases (time of returned from O.R, reaction from anesthesia
(level of conscious) condition of wound ,any devices attached to the pt.,
time, dose, name of any medication given to pt. after operation).
Cancelled operation cases (causes).
Post-pond operation cases (causes).
7- I.V cases:
Include the following information:
Total amount of I.V infusion, time of starting I.V, amount
received, amount still running, pt. reaction to I.V if occur,
time of reaction occurrence, action was done and result of
treatment.
8- Nasogastric tube cases:
Cause of insertion:
If for suction
Time of doing suction.
Characteristic of discharged (color, Oder, consistency).
Amount replayed by infusion or not
If for feeding:
Amount, types of food.
Time received.
If tube patent and in place or not.
9-Catheter cases:
Include the following information:
Types of catheter, place, patent or not, amount of urinary output
and its characteristics.
10- Dressing cases:
In case of septic wound, specific antiseptic solution or medication
used on dressing
In cases of removing sutures (number of sutures removed,
characteristics of wound specific antiseptic solution or medication
used on dressing.
Cases that needed specific observation for their condition for
anticipating complains may occur:
Dyspnea, medication prescribed, o2 inhalation.
Chest pain and give S.O.S medication.
Any deviation in vital signs, action taken, time of relieved
abnormalities and pt. progressed.
Watch for nausea and vomiting.
11- Comatose cases:
Include the following information:
Reaction to internal and external stimuli, vital signs, if pt. attached
to any devise must be reported about it e.g. (N.G.T, I.V, and
Catheter…..act).
12- Cases that get out unit for any cause:
Include the following information:
Pt. schedule for O.R and still there.
Pt. schedule for kidney dialysis and still there.
Pt. schedule for physiotherapy and still there.
Pt. go to x-ray department and still there.
13- Cases on monitor:
-In case of newly admitted and immediately attached to monitor.
Time of admission.
Time of attached to monitor.
Time, frequency of arrthymia
Action taken, medication given
Arrthymia if relieved or not
When arrthymia occur.
Time, frequency of arrthymia.
Action taken, medication given.
Arrthymia if relieved or not.
14- Cases on ventilator:
Include the following information:
Concentration of oxygen.
Humidified o2 inhalation cycle/ml.
Suction given and character of sputum.
Tracheostomy tube and dressing done on Tracheostomy.
Note any change in vital signs.
Note for loss of balance.
Application for daily shift report:
You are a team leader in surgical department, there are 13
patients and 20 beds, during your morning shift Pt. (A, 3)
improved umbilical hernia and will discharge today at 11:30
a.m. Pt. (B,3) postponed his operation (Splenectomy) due to
high blood pressure. Pt. (C, 1) excused for 3 days and will
return at 23/3/2023. Pt. (C, 3) diagnosed as gastric carcinoma
has recurrent episode of vomiting with blood clot after eating,
Dr ordered NPO& need close observation.
Daily shift report
Unit: Surgical department No. of beds: 20 Date: ……………..
H.N name:…………. No. of pts.: 13
Room No Diagnosis Summary on patient's condition
Room No Diagnosis Summary on patient's condition
Bed No
Bed No
Pt's name
Pt's name
A,3) Umbilical hernia Pt. discharged today at 11:30am, conscious, stable condition & his V/S
)B,3) Splenomegaly Temp: 37.2c, P: 90b/m, R: 18c/m, Bl.p:120/70mmhg, with intact skin,
follow up at……in Pt. clinical.
A,3) Umbilical Pt. discharged today at 11:30am, conscious, stable
Pt. postponed his operation (Splenomegaly) due to high blood pressure.
condition & his V/S Temp: 37.2c, P: 90b/m, R:
)B,3)(C,1) hernia
............. Pt. excused for 3 days and will return at 23/3/2023 due to family reason,
18c/m, Bl.p:120/70mmhg, with intact skin, follow
Pt. left the hospital at 11:00am, conscious, his V/S……., with intact skin,
&stableup at……in
condition. Pt. clinical.
Splenomegaly physical
(C,3) Gastric Pt. hasPt. postponed
recurrent episode of vomitinghis operation
with blood (Splenomegaly)
clot after eating. Dr. due to
carcinoma ordered high
NPO& needBlood Pressure.
close observation.
(C,1) ............. Pt. excused for 3 days and will return at
23/3/2023 due to family reason, Pt. left the
hospital at 11:00am, conscious, his V/S…….,
with intact skin, &stable physical condition.
(C,3) Gastric Pt. has recurrent episode of vomiting with
carcinoma blood clot after eating. Dr. ordered NPO&
need close observation.
