Nursing Report Principles Flashcards
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Questions and Answers

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)

  • Shift to shift (correct)
  • Email report
  • Telephone report (correct)
  • Report by fax
  • 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?

    <p>Situation, Background, Assessment, Recommend.</p> Signup and view all the answers

    In the SBAR framework, what does 'Situation' include?

    <p>The patient's age and hospital day</p> Signup and view all the answers

    What should the Background section of a report include?

    <p>Past medical history, unusual assessments, changes, treatments, and discharge plans.</p> Signup and view all the answers

    What information is covered in the Assessment section?

    <p>Current status, concerns or problems, unfinished cares, treatments, tests, and pending results.</p> Signup and view all the answers

    What does the Recommend section focus on?

    <p>The plan for the patient and care that needs attention.</p> Signup and view all the answers

    What factors can impact the effectiveness of a report?

    <p>Distractions</p> Signup and view all the answers

    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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    Description

    Explore key concepts of nursing report principles with these flashcards. Learn the purpose of nursing reports and the various types used in healthcare settings. Perfect for nursing students and professionals looking to enhance their communication skills.

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