Ideal Nursing ReportBy: Jeannie Manning : Ideal Nursing ReportBy: Jeannie Manning Ideal Nursing Hand Off Report : Ideal Nursing Hand Off Report Types of Communication tool
Anticipated & Barriers to discharge addressed
Care plan reviewed & updated
Bedside Nursing Reporting Patients Center of Care : Patients Center of Care Components of the Care Model
Compassion Communication During Transitions in Health Care : Patient Safety Accuracy Communication During Transitions in Health Care Structure Improve Continuity of
Care by Improving
Hand-offs Communication : Communication 44,000 to 98,000 people die each year as a result of medical error. Communication is one of the leading problems with medical error.
Communication impacts patient safety, and many times, breakdowns and causes problems.
Nurses know their handoff reports are important.
Its vital to pass all important but not superfluous information because timeliness is a vital aspect of their jobs. Types of Nursing Communication : Types of Nursing Communication Nurse-to-physician
Nurse-to-nurse Types of Handoffs : Types of Handoffs The FIVE-Ps
IPASS The BATON The FIVE Ps : The FIVE Ps Patient Name, Identifiers, age, sex, location
Plan patient Patient diagnosis, treatment plan, next step
Purpose Provide a rationale for the care of plan.
Problem Explain what’s different or unusual about the patient.
Precautions Explain what’s expected to be different or usual about the patient. SBAR Communication : SBAR Communication S-Situation: Identify yourself and position, patient’s name and the
current situation. Describe what is going on with
B-Background: State the relevant history and physical (H&P), physical assessment pertinent to the problem, treatment/clinical course summary and any pertinent
changes. SBAR Communication : SBAR Communication A-Assessment: Offer your conclusion about the present situation.
R-Recommendations: Explain what you think needs to be done, what the patient needs and when. IPASS The BATON : IPASS The BATON I –Introduction: Individuals involved in the handoff.
P- patient: Name, Identifiers, age, sex, location
A- Assessment: present chief complaint, vital signs, symptoms and diagnosis
S- situation: Current status and circumstances, including code status level of certainty or uncertainty, recent changes and response to treatment
S- Safety concerns: critical lab values and reports, socioeconomic factors, allergies and alerts, such as risk for falls. BATON : BATON B- Background: Comorbidities, previous episodes, current medication and family history
A- Action: Detail what action were taken or are required and provide a brief rationale for those actions
T- Timing: Level of urgency and explicit timing, prioritization of actions
O- Ownership: Who is responsible( nurse, doctor, team), including patient and family.
N- Next: What will happen next? Any anticipated changes? What is the plan? Any contingency plans. No Sidebar Conversations : No Sidebar Conversations Information that does not have anything to do with the patient.
What you are doing on your days off.
Gossip about other employees. Anticipated & Barriers to discharger : Anticipated & Barriers to discharger Poor communication between physicians and nurses as being responsible for discharge delays.
Waiting for procedures, tests, and laboratory results as being responsible for delays. Caredex Used : Caredex Used Use For Nursing Hand Off
Review Patients Care
Update Patient Information Change of Shift Reporting : Change of Shift Reporting The nurse also needs information about the patients he or she will be caring for. This is typically done as a “change of shift” report. Staff nurses view change-of-shift report as a critical event for exchanging patient information. To ensure continuity of care when the care is transitioned to the next nursing caregiver, the report must be broad enough to encompass the holistic and long-term goals of the patient, yet specific enough to meet short-term goals and offer individualized preferences to meet the patient needs. Traditional methods of shift report such as verbal and taped report tend to be lengthy, inconsistent, and have missing or incorrect elements of patient information. The content sometimes digresses to irrelevant or judgmental statements. This can lead to negative preconceptions by the oncoming nurse, omissions of relevant patient care, and complaints from patients, families, and physicians.
(Nurs Admin Q Vol. 30, No. 2, pp. 112–122 c 2006 Lippincott Williams & Wilkins, Inc. Cherri D. Anderson, MBA, RN, C;
Ruthie R. Mangino, MSN, APRN-BC) Bedside nursing Reporting : Bedside nursing Reporting Contains all the Components of the Care Model
Communication, Collaboration, Informing, Nursing care, Patient data,
Holistic care, Clinical excellence, Teams, Compassion. Pros And Cons Of Bedside Reporting : Pros And Cons Of Bedside Reporting Pros
The benefits of the proposed bedside report based on traditional report inefficiencies and identified problems with the current report process offer an immediate solution to many of the problems identified with other traditional methods. This new style of report is informative, shorter, more individualized, and involves the patient. It provides a win-win situation for the staff as well as the patients.
Issues with confidentiality, and fear of situations where patients would talk or ask questions for extended periods, thus increasing length of time for the report. Other concerns were related to the actual process itself, such as what to do if the patient does not know the diagnosis or test results yet; what if the patient is sleeping; and what if the patient is uncooperative with care and it needs to be reported to the oncoming shift. Patients understanding of the information being reported on. References : References Banner Health
Cherri D. Anderson, MBA, RN, C; Ruthie R. Mangino, MSN, APRN-BC http://www.mc.vanderbilt.edu/root/pdfs/nursing/who_says_you_cant_talk_in_front_of_the_patient.pdf