Daily Shift Report PDF

Daily Shift Report Lecture : Dr. Reem Mabrok Dr. Randa Mohamed Date : 26/ 11/2024 Definition of shift report It is a system of communication prepared by individuals delegated for tasks to bring from, or send information to others.  Importance of shift report 1) Pr...

Daily Shift Report Lecture : Dr. Reem Mabrok Dr. Randa Mohamed Date : 26/ 11/2024 Definition of shift report It is a system of communication prepared by individuals delegated for tasks to bring from, or send information to others.  Importance of shift report 1) Provides a mean of communication between professionals contributing to patients care. 2) Provides documentary evidence of the course of the patient illness and treatment during hospitalization. 3) Assists in protecting the legal interests of the hospital, physicians and nurses. 4) Serves as a basis of analysis, study and evaluation of quality of care provided to the patients. 5) Provides clinical data for research and education. 6) Serves as a basis for planning individual patient care. 7) Provides continuity of patient care on subsequent admissions. 8) Prevents duplication of effort and eliminates the need for investigations to learn the facts in a situation Types of shift report 1. oral 2. written 1- Oral report Oral reports are given when: Information is for immediate use and not for permanency. It may be based on material included in written report. e.g. Oral report given to the head nurse or charge nurse by all nursing personnel. Characteristics of good oral report: To be effective in reporting information, it must be exchanged in the following manner: 1) Those involved in reporting must value the exchange of information as important to the care of patient. 2) Patient data must be relevant, accurate and current. 3) The environment must be without distraction and must be comfortable to all involved. 4) Timing and duration should be acceptable to those involved.  Characteristics of good oral report Cont. 5) Participant in reporting should feel personally involved and accountable for transmitting and receiving information. 6) All participants in the reporting process should show interest, attentiveness, and respect. 7) Information should be personalized by patient’s name. 1) Important points are personalized Principles of written report The report should be: Complete, Clear and well organized. Written in ink. Signed, dated and timed. The signature should be with job title and name. No spaces should be left. If mistake was done, a single line over the mistake and sign above it. Every entry should be timed. It should contain the date, shift, head nurse’s name and the department. Written properly and with international abbreviations  Cases should be included in shift report ❑ All acutely ill and post-operative patients or patient who need frequent monitoring e.g.: - Comatose patients - On monitor or ventilator - IV and NGT ❑ Patients with any changes in general condition. ❑ Patients who have special treatment. ❑ Patients who need special preparation for next day e.g.: - Preoperative preparation - Lab investigation ❑ Admission, transfer, discharge and death.  How to write different cases in shift report? 1. Comatose patient At 12:00 md, is comatose, GCS is 3. Temp: ---, Pulse: ---, Resp: ----, and BP:-- 2. Patient on ventilator At 1:00 pm, attached with ventilator through endotracheal tube/tracheostomy in place and patent, (Mode: -----, T.V:---- RR: ---- ) and suction was done for three time during the shift, secretion was about 30cc sticky, greenish. 3. Patient on monitor At 12:00 md, attached with monitor, (type of arrhythmia, duration, frequency, action done) e.g. At 1:00 pm, attached with monitor, Premature ventricular beat 10/min, repeated for 4 times and Dr. Ahmed notified and ordered Amp ----- IV,  How to write different cases in shift report? Cont. 4. Tubes attached a.IV cases: At 12:00 md, pt attached with IV line, in place and patent, Total IV infusion 2400 cc/ 24 hrs,……………… If started and finished during the shift: At 11:00 am, received 500cc G 5%, total IV intake 500cc/shift. If finished one and started another: At 11:00 am, received 500cc G 5%, followed by 500cc N.S, at 1pm received 200 cc and still running, total IV intake 700 cc/ shift. If started and not finished: At 9:00 am, started 500cc N.S, at 1 pm received 200cc and still running, total IV intake 700cc/ shift. How to write different cases in shift report? Cont. b. Nasogastric tube cases At 12:00 md, attached with NGT for feeding in place and patent, total intake 2000cc/24 hrs, at (9 am, 11am, 1 pm) received 600cc/shift (milk, juice, vegetable soup). At 12:00 md attached with NGT for drainage. in place and Patent, output: 50 cc/shift yellow in color. a.Catheter cases At 12:00 md, attached with Folly’s Urinary Catheter, in place and patent, output 400 ml/shift red in color. How to write different cases in shift report? Cont. 5. Total intake: (All IV fluid + NGF) 6. Total output: (NG drainage + urine + any fluids from drain) 7. Fluid Balance: (Total intake – Total output) =…….. 8. Operation cases a) Scheduled for OR: ( At 12:00 md scheduled for OR. b) Immediately P.O: At 12:00 md immediately P.O. V/S: temp: ---, P: ----, Resp: ----, BP: ----, GCS ---, Attached with cannula in right arm, in place and patent. How to write different cases in shift report? Cont. c) Still in OR: (At 12:00 md, went to OR and still there) d) Operation cancelled or postponed: At 10:00 am, the operation postponed because temp 39°c by Dr/…….. At 11:00 am, the operation cancelled due to patient refusal to sign the consent. How to write different cases in shift report? Cont. 9. Patient Complaints You should write the time of complaint, the characteristics and the management done and the reaction after management. e.g. At 10:00 AM, temp:39.5°c, Dr. Ahmed notified, received Amp Aspejic IM and cold compresses for 15 mins on forehead repeated three times. At 11:00 am, temp 37°c. 10. Cases with dressing: In case of removing suture and septic wound. At 9:00 am, dressing on open septic wound in RT iliac region with removal of half suture, using Betadine and Fucidin ointment. Discharge was ……….. (Characteristics). How to write different cases in shift report? Cont. 11. Admission, discharge, transfer and death Written in the patient census and their numbers recorded at the end of the shift report. a.Admission Write the time of admission, the V/S, all tubes attached and complaints and management actions done. b. Discharge Write the number in the end of shift report sheet. c. Transfer to another unit Write complete information about the time of transfer, the unit to which the patient was transferred, all tubes attached to the patient, all medications given and last investigations done and the cause for transfer. How to write different cases in shift report? Cont. 12. Cases of medical permission Write the time of leaving the unit, cause, and scheduled time for coming back. At 10:00 AM, the patient left the unit for examination, pt was conscious, v/s-----. Scheduled to return back on 23/11/2020 at 11:00 AM e.g.: At 10:00 AM, pt went to Alex Scan for Abdominal CT and still there. Thank You