SHIFT CHANGE REPORT

(NURSING DOCUMENTATION)

Pre-intermediate Level
for S-1 Nursing Students 2008

Objective
After the class is over, the students
will be able to make a written SHIFT
CHANGE REPORT about the
nursing intervention done to patients
and their health condition

SHIFT CHANGE REPORT

SHIFT CHANGE REPORT is an action of
reporting important information about
the clients health condition and
nursing intervention during the shift
change.

In nursing, report is a meeting between

nursing staff members at shift change in
which information about patients is
exchanged.
Report is generally given by the nurses incharge of one shift to those coming on for
the next.

CHANGE OF SHIFT REPORT

Nurse shift changes require the successful
transfer of information between nurses to
prevent bad events and medical errors.
Patients and families can play a role to
make sure these transitions in care are
safe and effective.

VOCABULARY
Shift-change report
: Laporan pergantian shift
Off-going nurse
: Perawat yg sdh bebas tugas
Out-going nurse
: Perawat yg sdh bebas tugas
On-going nurse
: Perawat yg bertugas
Nurse in-charge
: Perawat yg sedang bertugas
Attending physician
: Dokter yg bertugas
Hand off the shift
: Menyerahkan shift
Occur
: Muncul
Information exchange : Pertukaran informasi
Taped report
: Laporan yg direkam di pita kaset
Written report
: Laporan tertulis
Verbal report
: Laporan per oral
Bedside report : Laporan yg melibatkan diskusi antara offgoing nurse, on-going nurse dan klien (di
sisi tempat tidur klien)

DESCRIPTION

Hospital opens 24 hours.

The nurses should work in shift system.
Three types of shift :
Morning shift
Day shift
Night shift

Sometimes, the nurses must work over time.

Before handing off the shift, the off-going nurse
must transfer the information (report) about the
clients health condition and nursing intervention to
the on-going nurse.
The problems of transferring information (report)
may occur during the shift change because of:
coming late
Bad hand writing

NURSING REPORT
During report, the outgoing nurses discuss with
the oncoming nurses the condition of each
patient and any changes that have occurred to
the patient during the shift.
For nurses who regularly work with these
patients, they can learn about any updates in the
conditions of the patients.
For nurses not normally assigned to the unit,
they will learn about the patients on the unit.
For all nurses, they will learn about any new
patients who have recently been admitted to the
unit.

Whats your opinion about ..

The importance of writing a shift

change report
Shift change report in written and
verbal form
Making shift change report is boring
and time consuming
Making a shift change report is
additional cause of stress in addition
to the strenuous (tiring) ward work

Shift change reports allow the off-going nurse to

communicate with the on-coming nurse about
the patient's case. Passing quality information
from one shift to the next promotes the patients
safety and health as well as enhances the
continuity of care. Taped (or written) reports and
verbal reports are traditional methods of
exchanging data during shift change, while
bedside reports are a new trend.

Shift change reports

1. Taped (or written) Reports
2. Verbal Reports
3. Bedside Reports

Taped (or Written) Reports

With taped or written reports, the off-going nurse

records patient information on audio tape or writes it

down on paper. Then, she returns to take care of
her patients. The on-coming nurse either listens to
or reads the report when she arrives on the unit.
Health care facilities may or may not have
guidelines about what information to include in the
report. Without guidelines, the quality of reports is
inconsistent from one nurse to the next. Information
may be redundant or irrelevant.
Because the two shifts do not meet face-to-face, the
on-coming nurse is unable to ask questions about
the patient. Important details may be missing from
the report, especially if the off-going nurse was
extremely busy.

Verbal Reports
With verbal reports, the on-coming nurse first

familiarizes herself with the patient by looking over the

Kardex. The Kardex is a card that lists basic
information such as name, age and diagnosis.
During the report, the off-going nurse talks about the
patient, while the on-coming nurse writes down
pertinent (relevant) data and asks questions as
necessary.
Verbal reports can last anywhere from 30 minutes to 1
hour. They often lack structure as nurses recollect
events that occurred during their shift rather than
provide essential patient information. A major
drawback of verbal reports is that it takes two nurses
away from the bedside; thus, patients may wait long
periods at shift change to see a nurse.

Bedside Reports
Bedside reports strive to correct the weaknesses of traditional

methods by including the patient in the process. The off-going

nurse introduces the on-coming nurse to the patient, and they
discuss his plan of care. By being in the room, the patient
listens to the report and is able to clarify areas that are
confusing. He can even ask questions about his care.
Individualized goals and patient progress are also included in
the discussion.
Therefore, the patient, the off-going nurse and the on-coming
nurse are aware of the plan of care. The bedside report
generally lasts several minutes per patient. It benefits the oncoming nurse because it allows her to meet the patient and
interact with him.
As a result, she is able to identify his needs and prioritize for
the shift. The off-going nurse may even show the on-coming
nurse how to use medical equipment in the room. When shifts
work together face-to-face, there is a teamwork spirit that
allows the nurses to achieve common goals.

Prerequisites for a good report

1. ACCURATE OBSERVATION
It is understood that you can only record fully
what you have observed accurately. The
important points to watch in-patients are
thought during your training in the various
disciplines. Dont forget that the more profound
your technical knowledge, the better you will
be able to judge the various situations
accurately and to recognize changes.

Prerequisites for a good report

2. ESSENTIAL INFORMATION:
1. Allergies
Allergy information is critical, because it may
dictate which medications can be safely
administered to a patient.
2. Code status
Code status includes information about whether
a patient needs resuscitation.
3. Medical team members and phone numbers.
Finally, oncoming nurses need to know the
members of the patients medical team in case a
nurse needs to call for help.
4. An outgoing nurse must inform the oncoming
nurse about a patients medical history and
current condition as well as the nursing
interventions done before.

Prerequisites for a good

report
3. ACCURACY
Never make approximate or
ambiguous statements. Avoid all
expressions, phrases, or
abbreviations that might create a
misunderstanding.

Prerequisites for a good report

4. BREVITY
Be brief! Overlong reports are tiring for the
reader. Essential information is often lost. The
idea is not to prepare a stylistically perfect
paper, but to give information completely and
accurately. Use unambiguous and current
abbreviations known to everybody.
Notes:
Abbreviations: a.c. (before meals), p.c. (after
meals), PRN (pro re nata = as necessary), pt
(patient), Tx (treatment), UTI (urinary tract
infection), URI upper respiratory infection, VS
(vital signs), 3X (three times), qd (everyday),
qh (every hour), pre-op (preoperative), post-op
(postoperative), Dx (diagnosis), CA (cancer),
bid (twice daily), Fx (fracture), G (gravida), etc.

Prerequisites for a good

report
5. OBJECTIVITY
Avoid all personal evaluation or
justification.
6. REALITY (TRUTH or VERACITY)
A nurse must be based on the truth.

Issues with report

While report is necessary in order to
communicate important information between
nurses, various problems are posed by the
giving of report.
Often, nurses during this time, since they are
busy with the reporting, are unable to attend
to other duties. Though a nurse is required to
do whatever is necessary in the event of an
emergency, many nurses will often refuse to
provide non-emergency assistance to
patients at their requests during report time.

Issues with report

Nurses in many places are legally not
permitted to leave the facility until they
have given report. Walking off the job may
be considered abandonment, which may
be grounds for revocation of the nurse's
license. At the same time, facilities are not
legally required in all places to pay nurses
for the extra time beyond their shift they
are forced to stay over to complete report.
While privacy laws require report to be
given in a location where patients, visitors,
and non-nursing staff cannot hear the
report, some facilities prohibit family
members from visiting patients during
report times.

NOTES

The work schedule and the situation of the patients

are negatively affected if reports are not carefully
prepared, worded, and relayed. In extreme cases,
necessary medical help may be omitted because of
inaccurately formulated reports.
Please bear in mind that a well prepared report also
saves time by eliminating the need for additional
questions and permitting the immediate application of
nursing and medical measures.
Reliable reports also give you confidence in your
actions, which is essential for your dealings with the
patients. In the course of your work, you will certainly
feel the negative consequences of badly prepared
reports in everyday ward work and be annoyed by
them.

INFORMATION
written in the shift-change report

Patients name, age, room, and bed number

Date and time
Diagnosis
Attending physician (doctor in-charge)
Complaints = subjective data
Vital signs measurement, signs of problem, and result of
observation (including lab test result) = objective data
Nursing intervention
Patients important activities related yo the problems (such as,
therapy) and special needs (if necessary)
Doctors instructions (advices)
Medication (medicines)
Nurses name and signature

WRITING: Nursing report

Feb 17th, 2008

Ms. B had a peaceful night. She slept until 03.00
hrs. At 06.00 hrs, she was handed a washbowl of
water and washed herself. Ms. B found that it was
too strenuous to use a bedpan. The physician has
permitted her to use the toilet seat next time. At
10.00 hrs, the cannula bandage and the perfusor
system were changed.
Feb 18th, 2008
At 06.00 hrs, the patient was handed the
washbowl and the toilet utensils. She washed
herself alone. Due to the reduced mobility of the
hip, her legs must be washed for her. At 10.00
hrs, the cannula bandage and the perfusor
system were changed. The patient was prepared
for low-fat diet: it was explained to her why she
mustnt eat butter, fatty cheese or sausage and
was told about diet counseling. During the
rounds, a slight exsiccosis was diagnosed.

Feb 19th, 2008

Ms. B 29 y.o.
At 06.00 hrs, the patient was handed the washbowl and the
toilet. Her legs were washed. Ms. B has had a bad night. At
10.00 hrs, the bladder catheter was removed. At 10.30 the
cannula bandage and the perfusor system were changed;
no signs of inflammation. Ms. B was delighted by the visit of
her relatives, At 16.00 hrs, she was unable to urinate
spontaneously (physicians order: one tablet of Doryl). The
sheets were changed. She sits on the edge of her bed for
each meal.
Feb 20th, 2008
Ms. B took a little walk in the corridor. She was very pleased
with her progress. Now she would like to spend some time
of the day with other patients.
Feb 21st, 2008
During the rounds, the physician has decided to discharge
Ms. B on Feb 25th. She will practice climbing the stairs on
Feb 24th.
2

WRITING: Nursing report

Feb 22nd, 2008

Ms. B took a shower and washed her hair.
Feb 23rd, 2008
At 14.00 hrs, Ms. B went to the caf together with her
relatives. She enjoyed this little outing very much. She laid
in bed and was in a good mood.
Feb 24th, 2008
At 12.00 hrs, no problems with climbing the stairs (12
steps, physiotherapist). At 14.00 hrs, diet counseling
together with the patients relatives (assistant dietician).
She practiced climbing the stairs at 15.00 hrs.
Feb 25th
Discharge from hospital.

Mz. Liza, 23 y.o., Melati Room

March 26, 2013

Dengue fever
Dr. Effendi Subagyo, Sp.PD
Pt says she has had a fever, headache, nausea and vomiting for 3
days. The temp is up and down.
BP: 120/80 mmHg T: 39o C
P: 100 times/mins
Rr: 20 times/mins
Fatigue, redness on face, warm acral (hand and foot palms)
Doctors advices:
R/L Infusion 20 drops/mins
Novalgin injection
Cedantron 2x/day

Warm compress, drink much water, wear thin clothes, set the room
temperature within normal.
Lab test: DL and Widal test
Susan Sarandon
(Signature)

PRACTICE MAKES PERFECT