RE P OR T S
[Link]
Devi
Professor
RHIPL
INTRODUCTION
Communication is corner
stone in the nursing professional
& essential part of the nursing
care.
Nurses communicate
information about client’s/
patient’s so that all health care
team members can make
appropriate decision making
about client’s care.
REPORTS
Oral, written, or
computer-based action
intended to convey
information to others is
called as report.
In other words,
reporting is the process of
informing the other staff
about the patients & of
other events.
Report can either be
ur p o s e of
P
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u n i c r s o n
Comm ion to a pe
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i n fo o f s t a ff
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d r a p o r t
To im
e r t a i n s .
c r f a c t
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[Link] of Shift
Report
[Link] Report
[Link] Report
[Link] Reports
E. Conferring
G . F.
Intra departmental
Intra divisional reports
reports
[Link] of Shift
Report
Report
It is the report which
is given to all nurses
on the next shift.
It enhances
continuity of care of
patients by providing
a quick summary of
client needs & details
of care to the
oncoming staff in the
next shift.
EXAMPLE FOR CSR
If first shift nurse finds a certain pain
relief measure effective for a client, it is
essential that the information be related
to the next nurse caring for the client so
that pain control intervention can be
continued.
The essential points to consider
during this report
The information should
be accurate, factual &
organized.
Avoid subjectivity &
negativism while
reporting.
Use written guide to
prompt thoroughness &
organization.
Be specific.
Focus on abnormal
findings & variation from
the usual or the norm.
Vital Signs
Medical
&
History
Assessments
Current Treatment
Status Summary
Key
Components Concerns
Patient
Identification of a Change &
Recommendations
of Shift
Report
Key Components of a Change of Shift
Report
•Patient Identification: Name, room no.,
age & gender.
•Current Status: Overview of the patient's
condition (e.g., stable, critical) & primary
diagnosis.
•Medical History: Brief summary of relevant
medical history & admission details.
•Vital Signs & Assessments: Most recent
vital signs & any significant physical exam
findings.
•Treatment Summary: Overview of
treatments administered, including
medications & any pending tests or
Types of Change of Shift Report
Written Verbal Report Bedside
Report Report
The off-going The off-going The off-going
nurse records nurse gives nurse
patient over verbally to introduces the
information & the on-coming on coming staff
writes it down staff about the to the patient &
on the report patient & other they discuss his
book. pertinent plan of care.
On-coming information It lasts several
nurse either about the ward. minutes per
listens to or Verbal report patient.
reads the occurs either in It allows the on-
report when the duty room coming nurse
she arrives on or during a to meet the
B. Telephone Report
Nurse receiving a
telephone report
should document the
date & time, the name
of the person giving
that information & the
subject of the
information received.
Telephone reports
usually include the
clients name, medical
diagnosis, etc.
The nurse giving the
telephone report
GUIDELINES FOR TELEPHONE
REPORTS
It should be clearly patient name, room,
unit no, IP number & diagnosis.
Repeat the reports any communication
error occur
Use clarification questions to avoid
misunderstanding.
C. Transfer Report
Transfer report is related to
transferring a patient from one
unit to another.
Important points to report
during a patient transfer
includes the following:
Background information of the
patient, current status, medical
progress, current nursing
diagnosis, critical assessment
or interventions to be
D. Incident Reports
Incident reports are used to document any unusual
occurrence or accident in the delivery of client care
such as falls or medication errors.
It improves the management & treatment of
patients by identifying high risk patterns & to initiate
in-service programs in order to prevent similar
problems in the future.
Incident reports should be concise & accurate.
The details should be reported exactly on what was
observed & what action was taken. Never explain
the cause or make excuses & don't place blame in
TYPE OF INCIDENTS
Falling from bed or in toilet
Needle stick injuries
Burns (hot Application or from other
sources)
Drugs or medications administration
errors
Misidentification of patient
Accidental omission of ordered therapies.
GUIDELINES TO REPORT INCIDENT
•Describe in concise what exactly
happens especially in objective terms.
•Enumerate incident unit, time etc
• Explain patient condition before & after
the incident (physical & psychological)
•Describe any treatment is given after
incident
•Record patient vital sings after incident
•No nurse should blamed in an incident
reports
E. Conferring
These are reports
regarding consultations
& reference, nursing
care conferences,
nursing rounds,
procedures done to
obtain information that
will help to plan
nursing care &
evaluate the nursing
care the client has
F. Intra Divisional
F. Intra Report
Division
These reports can
take place among
the nursing staff
between nursing
alsisters
Reports (ward in-
charges) & staff
nurses, between
Nursing sisters &
Matron (Nursing
Superintendent), &
between nursing
sisters & doctors.
G. Intra Departmental Reports
This report occurs between the nursing
matron & medical superintendent.
The nursing superintendent sends the
report of patients to the medical
superintendent through a report book.
The report is usually related to VIP
patients or ill mishappenings, patients,
accidents, any disaster/event/ complaints,
performance report, etc.
CRITERIA OF GOOD
REPORT
Can be made promptly
Clear, Concise &
Complete
All pertinent, identifying
data included.
Mention all people
concerned, situation &
signature of person
making report
Easily understood