Shift Report Methods and Importance

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Questions and Answers

What is the primary purpose of a shift report?

To facilitate communication among healthcare professionals regarding patient care.

List three benefits of maintaining a shift report.

Provides continuity of care. 2) Supports legal interests. 3) Aids in quality care evaluation.

When is it appropriate to use an oral report?

When information is needed for immediate use and not for permanent record.

What are two characteristics of a good oral report?

<ol> <li>Relevant, accurate, and current information. 2) An engaging and distraction-free environment.</li> </ol> Signup and view all the answers

What principle should be followed when writing a shift report?

The report should be complete, clear, and well organized. Signup and view all the answers

Why is it important to sign and date a shift report?

It provides accountability and verifies the authenticity of the report. Signup and view all the answers

What should be done if a mistake is made in a written report?

Draw a single line over the mistake and sign above it. Signup and view all the answers

What role does shift report play in research and education?

It provides clinical data that can be used for analysis and learning. Signup and view all the answers

What key information should be included in a shift report for a comatose patient?

GCS score, temperature, pulse, respiration, and blood pressure. Signup and view all the answers

How would you document the care of a patient on a ventilator in a shift report?

State the time, mode of ventilation, tidal volume, respiratory rate, and any suctioning activities. Signup and view all the answers

What is the format for reporting IV intake if a new IV solution is started during the shift?

Document the time, volume received, followed by the new solution and total IV intake for the shift. Signup and view all the answers

What measurements should be included when documenting a patient with nasogastric tube (NGT) drainage?

Total intake over 24 hours and the output color and volume during the shift. Signup and view all the answers

When documenting catheter output, what specifics should be noted in the shift report?

The volume of urine output and its color should be recorded. Signup and view all the answers

What is included in the total intake for a shift report?

All IV fluids plus nasogastric feeding amounts for that period. Signup and view all the answers

For a patient undergoing preoperative care, what should be reported during the shift?

Document any special preparations, lab investigations, and changes in the patient's condition. Signup and view all the answers

What details are necessary for documenting a patient's condition change in a shift report?

Include the time of assessment, specific changes observed, and any actions taken. Signup and view all the answers

What is the formula for calculating fluid balance?

Fluid balance is calculated using the formula: Total intake – Total output. Signup and view all the answers

How should you document a patient's condition if they are scheduled for an operation but are still in the OR at noon?

Document 'At 12:00 md, went to OR and still there.' Signup and view all the answers

What details should you include when writing about patient complaints?

Include the time of the complaint, characteristics, management actions taken, and the patient's reaction after management. Signup and view all the answers

When reporting an admission, what critical information must be recorded?

Document the time of admission, vital signs, all tubes attached, patient complaints, and management actions done. Signup and view all the answers

What should be included in the shift report regarding a patient's transfer?

Include the time of transfer, the unit transferred to, all tubes attached, medications given, last investigations done, and the reason for transfer. Signup and view all the answers

How would you document a patient's temperature rise and subsequent treatment? Give an example.

Document: 'At 10:00 AM, temp 39.5°c, Dr. Ahmed notified, received Amp Aspejic IM and cold compresses for 15 mins.' Signup and view all the answers

What details are required when writing about a case with dressing changes in a septic wound?

Record the time, description of the wound, the procedure done, medications used, and the characteristics of the discharge. Signup and view all the answers

What information is crucial when documenting medical permissions for a patient leaving the unit?

Include the time of leaving, reason for leaving, and the scheduled time for returning. Signup and view all the answers

Study Notes

Daily Shift Report

Lecture given by Dr. Reem Mabrok and Dr. Randa Mohamed on 26/11/2024
This presentation is from King Salman International University (KSIU)

Definition of Shift Report

A system of communication where individuals delegated tasks exchange information.
It's a method of conveying information between individuals responsible for tasks.

Importance of Shift Report

Report serves as communication for professionals treating a patient.
It documents patient illness and treatment details during hospitalization.
Report keeps legal documentation and interest of staff protected.
It's helpful in analysis, evaluation of care provided to patients
Clinical information for both research and education.
It forms the basis of patient care plans.
It provides continuity of care, especially with subsequent patient admissions.
Reduces duplication of efforts and unnecessary investigations.

Types of Shift Report: Oral

Information is for immediate use, not permanent record.
Data may be based on prior written reports.
Information shared verbally to Head Nurse or Charge Nurse by nursing staff.

Characteristics of a Good Oral Shift Report

Report exchange should be valued as crucial to patient care.
Patient data needs to be accurate, relevant, and up-to-date.
The reporting environment should be free of distractions and comfortable.
The timing and duration of the report exchange should be appropriate.
Participants involved should be accountable and feel invested.
Active listening and respect from everyone involved.
Personalization of the report, using patient names.
Crucial details need to be highlighted.

Principles of Written Shift Report

Reports need to be organized, clear and complete.
Written in ink, and timed.
Signatures should be present along with job title and date.
No empty spaces in the report.
Errors should be corrected with a line through them and a revised signature.
Every entry should be timestamped.
Reports should include date, shift, head nurse's name, and department.
Proper use of international abbreviations required.

Cases Included in Shift Report

Acutely ill patients, post-operative patients, and those requiring frequent monitoring (e.g., comatose patients, patients on monitors or ventilators, IV and NGT patients).
Patients with changes in general condition, special medical treatments, and those needing special prep for the next day (like pre-operative prep, lab investigations).
Admissions, transfers, discharges, and deaths.

How to Write Different Cases in Shift Report

Comatose patient: Time, Glasgow Coma Scale (GCS) score, temperature, pulse, respiration rate, and blood pressure.
Patient on ventilator: Time of attachment, type of ventilation mode, tidal volume, respiratory rate, suctioning logs, and secretions.
Patient on monitor: Specific time, type of arrhythmia, duration, frequency, and any actions taken.
Tubes attached (IV): Time of placement, type of fluid given, total fluid intake for 24 hours, whether started and finished during the shift, intake volume.
Nasogastric tube (NGT) cases: Time of placement, reason for use (feeding or drainage), intake volumes, drainage volume and color
Catheter cases: Time of insertion, type of catheter (FOLLY’s Urinary Catheter), output volume, and color.
Total intake, output, and fluid balance: All items in the patients care calculated and recorded.
Scheduled OR cases: Information before or after surgery recorded.
Immediately P.O. cases: Vital signs immediately post-operative.
Cases still in OR: Patient still in operating room.
Operation canceled or postponed: Reasons for cancellation or postponement, and if temp 39.5 °C by the doctor
Patient complaint: Date, time of the complaint, symptoms' characteristics, interventions and reaction.
Dressing Cases: Date, time of dressing, wound description, and the materials utilized.
Admission, discharge, transfer, and death cases: Time of admission or discharge, vital signs, details of attached tubes, treatment given and other important information and cause.
Cases regarding medical permission: Time of leaving, reason for leaving, and planned return date.

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Description

This quiz covers the definition, importance, and types of shift reports in healthcare communication. It emphasizes the role of shift reports in supporting patient care and ensuring effective information exchange among medical professionals. Test your knowledge on how shift reports contribute to patient treatment, legal documentation, and healthcare analysis.