Podcast
Questions and Answers
What is the purpose of a nursing report?
What is the purpose of a nursing report?
- To effectively communicate specific information to another person or group (correct)
- To confuse the healthcare provider
- To document without context
- To share irrelevant information
Which of the following are types of nursing reports? (Select all that apply)
Which of the following are types of nursing reports? (Select all that apply)
- Shift to shift (correct)
- Email report
- Telephone report (correct)
- Report by fax
What should a shift to shift report include?
What should a shift to shift report include?
Background information, diagnosis, treatment plan, new orders, mental status, activity, equipment, IV info, lab results, pain levels, response to treatment, change in status.
What does SBAR stand for?
What does SBAR stand for?
In the SBAR framework, what does 'Situation' include?
In the SBAR framework, what does 'Situation' include?
What should the Background section of a report include?
What should the Background section of a report include?
What information is covered in the Assessment section?
What information is covered in the Assessment section?
What does the Recommend section focus on?
What does the Recommend section focus on?
What factors can impact the effectiveness of a report?
What factors can impact the effectiveness of a report?
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Study Notes
Purpose of Nursing Report
- Facilitates effective communication of vital information between healthcare providers.
- Must be concise and relevant to client care.
- Involves sharing data from one nurse to another or with other healthcare professionals.
Types of Nursing Reports
- Shift to Shift Report: Transition of care duties from one nurse to another during shift changes.
- Telephone Report: Information relayed via phone, especially when dealing with external sources, for patient care in acute settings.
- Establishes responsibility for patient care to another licensed professional.
Content of Shift to Shift Report
- Should encompass background information, current diagnosis, treatment plans, new medical orders, mental health status, patient activity, equipment used, IV details, lab result trends, pain management and response, any changes in patient status, and information on tubes or drains.
SBAR Format
- Situation: Current state of the patient and immediate concerns.
- Background: Relevant clinical history and context of the patient's condition.
- Assessment: Personal evaluation of the patient's issues or problems.
- Recommend: Suggested actions and plans for patient care.
- Standardizes communication and sets expectations for information exchange.
Detailed Elements of SBAR
- Situation: Includes patient's name, room number, age, physician details, days in the hospital or post-op, admission reason, diagnosis, and relevant issues such as allergies.
- Background: Accounts for medical history, specific assessments, changes in health or activity levels, and family responses regarding treatment and discharge plans.
- Assessment: Focuses on the patient's current status and any unresolved issues needing attention.
- Recommend: Outlines proposed care plans and indicates necessary communication with physicians.
Factors Impacting Report Quality
- Distractions: Interferences such as IV alarms, phone calls, or interruptions from patients can hinder effective report transmission.
- Listening Skills: Poor listening can lead to significant miscommunication.
- Communication Errors: Issues may arise from inadequate or inaccurate information sharing, including lab data or patient activity levels.
- Physical State: Factors like fatigue or negative body language can affect the delivery and reception of important information.
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