REPORTING
I. Definition:
A report is oral, written, or computer-based communication intended to convey
information to others.
II. Purpose:
1. To communicate specific information to a person or group of people
III. Types of Reports
A. CHANGE-OF-SHIFT REPORT OR “HANDOFF” COMMUNICATION
It is a process in which information about the patient/client/resident care is communicated
in a consistent manner including an opportunity to ask and respond to questions. This may be
written or given orally, either face-to-face exchange or by audiotape recording.
Face-to-face report provides opportunity for the incoming nurse to ask questions during
the report and address concerns. It can be done in a designated room, nurse’s station, or at the
client’s bedside.
Written and tape-recorded reports are shorter and less-time-consuming but verbal
updates may be needed.
Example: Handoff of a client, who was admitted in ER and transferred to ICU, from nurse to
nurse, physician to physician, and other health care provider.
Key Elements for Effective Handoff Communication:
The communication should include the following:
1. Up-to-date information
2. Interactive communication allowing for questions between the giver and receiver of
client information
3. Method for verifying the information (e.g., repeat-back, read-back techniques)
4. Minimal interruptions
5. Opportunity for receiver of information to review relevant client data (e.g., previous
care and treatment).
Sample Handoff Communication Tools (Association of Operating Room Nurses):
1. I PASS the BATON: Introduction, Patient, Assessment, Situation, Safety Concerns,
Background, Actions, Timing, Ownership, Next
2. I-SBAR: Introduction, Situation, Background, Assessment, Recommendation
3. PACE: Patient/Problem, Assessment/Actions, Continuing (treatments)/Changes,
Evaluation
4. Five-P’s: Patient, Plan, Purpose, Problem, Precautions, Physician (assigned to
coordinate)
SBAR Communication Tool:
allows for an easy and focused way to set expectations for what will be communicated
and how will they be communicated between members of the team, which is essential for
developing teamwork and fostering a culture of patient safety
S = Situation
• State your name, unit, and client name.
• Briefly state the problem.
B = Background
• State client admission diagnosis and date of admission.
• State pertinent medical history.
• Provide brief summary of treatment to date.
• Code status (if appropriate).
A = Assessment
• Vital signs
• Pain scale
• Is there a change from prior assessments?
R = Recommendation
• State what you would like to see done or specify that the care provider needs to come
and assess the client.
• Ask if health care provider wants to order any tests or medications.
• Ask health care provider if she or he wants to be notified for any reason.
• Ask, if no improvement, when you should call again.
Sample of SBAR Communication Tool
S= Situation
Good morning! I am Nurse __________, from ER and I am endorsing patient DE LA
CRUZ, JUANA, 75 years old, female, married with chief complaints of non-productive
cough and difficulty of breathing.
B= Background
This patient’s working diagnosis is Chronic Obstructive Pulmonary Disease and was
admitted today, January 3, 2019 at 2pm. She has been diagnosed with PTB 3 years ago,
has completed the treatment; no history of HPN, DM. O2 inhalation has been started at 2-
3 liters/min via nasal prongs. She has received the following medications in ER:
Hydrocortisone 100mg IV. I have given the first dose of Ampicillin-sulbactam 1.5 grams
IV after a negative skin test. The next dose will be 12mn. I have given the prescription to
her sister for acetylcysteine and symbicort inhaler, kindly give the 1st dose once the
medications will be available. PAI with Salbutamol was done 3x and the next dose will
be at 8pm. She has a signed DNR (Do not resuscitate) waiver.
A= Assessment
Her latest V/S are: BP=110/80mmHg; PR=98 beats/min; RR=32 breaths/min;
T=36.50C/axilla; O2 sat = 93%; Her difficulty of breathing was lessened, not as restless as
when she came but with nasal flaring, uses her accessory muscles while breathing and
with intercostal retractions; her lips and nail beds are cyanotic.
R= Recommendation
Vital signs should be monitored every 15mins until stable.Kindly have the resuscitation
equipment available at bedside. Blood samples for CBC and other laboratories have been
taken. Kindly inform Dr. ________ once her ABG result is in. Once restlessness,
decreasing level of consciousness and worsening of other signs and symptoms are noted,
please refer to Dr. ______.
B. TELEPHONE REPORTS
Nurse receiving the report:
Document date and time, name of person giving the information, subject of information
received, sign the notation.
Repeat back the information to the sender to ensure accuracy
Nurse giving the report to a primary care provider or doctor:
Be concise and accurate.
Use SBAR communication tool.
Include client’s name and medical diagnosis, changes in nursing assessment, vital signs
related to baseline vital signs, significant laboratory data, and related nursing
interventions.
Have the client’s chart ready to give the primary care provider any further information.
After reporting, the nurse should document the date, time, and content of the call.
C. TELEPHONE ORDERS
Guidelines:
1. Know the agency’s policy regarding phone orders (e.g.,colleague listens on extension and
cosigns order sheet).
3. Ask the prescriber to speak slowly and clearly.
4. Ask the prescriber to spell out the medication if you are not familiar with it.
5. Question the drug, dosage, or changes if they seem inappropriate for this client.
6. Write the order down or enter into a computer on the physician’s order form.
7. Read the order back to the prescriber. Use words instead of abbreviations (i.e., “three times a
day” instead of “tid”).
8. Have the prescriber verbally acknowledge the read-back (i.e., “Yes, that is correct”).
9. Record date and time and indicate it was a telephone order (TO). Sign name and credentials.
10. When writing a dosage always put a number before a decimal (i.e., 0.3 mL) but never after a
decimal (i.e., 6 mg).
11. Write out units (i.e., 15 units of insulin, not 15 u of insulin).
12. Transcribe the order.
13. Follow agency protocol about the prescriber’s protocol for signing telephone orders (i.e.,
within 24 hours).
• Never follow a voice-mail order. Call the prescriber for a client order. Write it down and read it
back for confirmation.
D. CARE PLAN CONFERENCE
- A meeting of a group of nurses to discuss possible solutions to certain problems of a
client, such as inability to cope with an event or lack of progress toward goal attainment
Purpose:
1. To allow each nurse an opportunity to offer an opinion about possible solutions to the
problem.
Note:
Other health professionals may be invited to attend the conference to offer their
expertise; for example, a social worker may discuss the family problems of a severely
burned child, or a dietitian may discuss the dietary problems of a client who has
diabetes.
Effective care plan conference include:
- Climate of respect
- Non-judgmental acceptance of others despite the differences in values, beliefs,
and opinions;
- Listening with an open mind to what others are saying even when there is
disagreement
E. NURSING ROUNDS
- A procedure in which two or more nurses visit selected clients at each client’s bedside
Purposes:
1. To obtain information that will help plan nursing care
2. To provide clients the opportunity to discuss their care
3. To evaluate the nursing care the client has received
Important!
Use terms that the client can understand because medical terminology excludes the client
from discussion.
