Nursing Shift Change Report Tips

Nursing shift change reports are commonly used when changing shifts at the hospital or any healthcare facility. They serve as a communication tool between the current and oncoming nurse. It conveys several key aspects of the patient’s care and is a very important communication tool between nurses. 

Nurse shift change reporting tools also improve communication amongst nurses and help nurse managers with staffing assignments. 

Let’s review some key aspects of a nurse shift change report and tips to improve your report.

Nurse Report Sections

Every nurse report will look different depending on the unit you work on. For example, a rehabilitation nurse report will need more information about activities of daily living and discharge plans. While an intensive care unit nurse will need information about ventilator settings, intravenous (IV) drips, procedures, etc. In general, nursing shift change reports follow an SBAR (situation, background, assessment, recommendations) format.

Situation

The situation section gives a general overview of the patient. This section includes some brief patient identifiers, such as name, sex, and age. 

You do not want to include specific patient identifiers, like date of birth. This is because if you misplace your report sheet then someone could read the patient’s protected health information.

The situation section also includes standard information of why the patient is at or admitted to the healthcare facility. Also, include isolation or special precautions and family contact information. Sometimes this information is hard to locate in the patient’s chart, so it’s useful to pass this along during shift change.

Background

The patient’s background is another important aspect of a nurse shift change report. It includes the patient’s past medical and psychosocial history. These histories can indicate chronic health conditions that may impact the patient’s plan of care. 

Nurses should also include a background or outline of the patient’s entire hospital stay. The outline gives pertinent medical information or procedures. For example, if the patient underwent any procedures, surgeries, transfers to other units, or cardiac resuscitation.

Most hospitals participate in interdisciplinary rounds, where core measures are reviewed. It’s important during shift change report to communicate the core measures and their outcomes. Core measures vary per unit, so make sure you know and understand your unit's core measures, even if you’re a night shift nurse.

Assessment

For nurses, the assessment section is inarguably the most important part of a nurse shift change report. Reporting your patient’s current mental status, vitals, medications, and physical exam is important. 

If there are any changes from a nurse’s report to a new nurse's physical assessment, this indicates that something may be worsening or improving with the patient. 

If symptoms are worsening or there is a change, it alerts the nurse to escalate the situation to the appropriate physician. If the patient is improving, the nurse can discuss this with the physician and the patient can potentially be transferred to another unit or discharged.

Recommendations

The recommendations section reviews the patient’s plan of care and daily goals. It gives the oncoming nurse ideas for daily or long-term goals, so they can communicate these to the patient, their family members, and healthcare team. 

Some common items to review in the recommendation section are upcoming procedures, labs, plan of care, and anticipated discharge or transfer. Updating the oncoming nurse about upcoming procedures are important, as the patient may need to be NPO (nothing by mouth) before their scheduled procedure. Labs are also vital for patient monitoring, such as partial thromboplastin time (PTT), for monitoring a therapeutic heparin infusion. Always verify labs and orders in the chart before starting your shift.

Ways to Improve Your Report

Whether you’ve given a shift change report once or 1,000 times before, there’s always room for improvement. Let’s review some ways to improve your shift change report.

• Give report at the bedside: It’s best practice to complete nurse shift change reports at the bedside. Bedside report can improve patient outcomes and help nurses determine any changes in acuity and verify IV drips, or ask any questions, if necessary. 

• Pull up the chart at the bedside: Pulling up the chart at the bedside allows for the oncoming nurse to review and verify the report information. This is especially important when communicating lab values, orders, core measures, or signing off on IV drips.

• Give major updates: If the oncoming nurse had the patient the day or night before, give them major updates. This doesn’t require a full report again.

• Ask if there are any questions: Always ask the oncoming nurse if they have any questions. This ensures that the oncoming nurse understands the patient’s plan of care or would like to verify an item from your report.

• Work together: We all know sometimes shift change arrives when your patient recently becomes unstable. Instead of giving a shift change report and leaving, ask the oncoming nurse what you would like to help with and be proactive. If a continuous IV infusion is about to run out, spike a new bag. Or if there is a lab draw that is due within the next 30 minutes, draw the patient’s blood for the nurse and deliver it to the lab. 

Shift change report improves nurse communication, especially when a specific format is used. Whenever possible, a shift change report should be completed at the bedside. Try some of these tips today to improve your bedside reporting skills.