January 29, 2015
Article by Global Pre-Meds
Hospital doctor shadowing & global health experience programs.
Some nurses call it handoff; others call it patient report. Whichever way you refer to it, giving report is an important part of your job as a nurse. Giving a thorough and accurate report is something you must start to learn in nursing school.
Report or handoff involves providing information to the nurse who will be taking over the care of your patients. It should be given anytime patient care is transferred to another nurse. This may include at the end of your shift or if a patient is being transferred to another unit in the hospital.
Report is essential to provide the oncoming nurse with information about the patients he or she will be caring for. If important information is missed in the report, it can affect patient care and safety. The transfer of information from one nurse to the oncoming nurse should provide an opportunity to ask questions and clarify anything that is unclear.
As a student nurse, you will likely be asked to provide report on the patients you cared for during your shift. Each facility may have slightly different policies for giving report, but the basics are usually the same.
The purpose of report is to provide information about the patients you cared for. Although the information should be in the patient’s chart, it is often more practical to present a brief synopsis of what is going on with the patient.
When you are giving report, it is helpful to have notes you took in front of you. You should have made some notes when you received report at the start of your shift. In addition, you will likely have written down information throughout the course of your workday.
SBAR is an acronym, which may help you stay organized and provide a good report. Each letter stands for an important segment of information that should be included in patient handoff.
Situation: Situation refers to the patient’s diagnosis and events of their current hospitalization. During this part of the report, it is important to mention the patient’s vital signs during your shift.
Background: The next component of report is the patient’s background or past medical history. Although the patient may be in the hospital for one illness, it is helpful to know what other conditions they have or had in the past.
Assessment: Information you gathered in your assessment comes next. This includes anything that stands out during your review of body systems. Information on medication and diet should also be included.
Recommendations: Lastly, recommendations includes what tests or procedures the patient will be having or issues, which still need to be addressed.
Tips for Success
You only have limited time during report. Don’t tell the patient’s life story. Keep things relevant
Spend a few minutes gathering information you need for the report before you start
Have access to the patient’s chart in case you need to clarify something
Be mindful of who is around and how loud you are speaking during report. Don’t forget about the patient’s right to privacy