Shift Report Methods and Importance

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.