Guidelines for Change of Shift Report **

(Required Reading Before Clinical Rotation)—On First Exam

 

 

1.    Patient’s name, date of admission, diagnosis, attending physician

 

2.    Assessments:

       a)    physical (lung, bowel sounds, neuro status, motility status, comfort, etc.-- whatever is relevant to the client’s problem(s)

       b)    emotional responses, if pertinent

       c)    be specific:  describe--don’t say “good”, “poor”

 

3.    Fluid status

       a)    intake totals, including:

               (1)   po--how much and how tolerated; enteral feedings

               (2)   IVs--how much in, type, rate, amount left in bag, site and system condition      

       b)    output:  self, Foley, chest tube drainage, diarrhea; totals (include if need prn cath’ing, when last done, how much obtained)

 

4.    Nursing interventions and responses

       a)    effects of critical procedures (e.g. blood transfusion, Solcatrans, special medications) ***

       b)    effects of interventions, medications

       c)    any unexpected outcomes

       d)    any diagnostic value of abnormal range, how affecting treatment regime

       e)    special diagnostic procedures (e.g. MRI, endoscopy, etc.), effect and nursing care given

       f )    do not review routine care procedures or normal vital signs (unless this is a change)

 

5.    Any unusual occurrences/changes in client’s condition.

 

6.    Client/family teaching needs identified, teaching completed and client responses.  (Should be documented on patient education form.)

 

7.    Newly identified nursing needs:  interventions initiated, changes suggested in care plan

 

8.    Changes in physician’s orders and client responses

 

9.    Any consults (e.g. PT, OT, social services, discharge planner, ST)  Any changes in care plan as result.

 

10.  Anything happening with client’s social support system which may affect plan

 

11.  Summarize priorities for next shift, including anything left undone from your shift

 

 

**  This is a framework or guide.  Report must be individualized to the particular situation--client and organization.

 

*** Report on a post-op patient is a very specific one.