Importance of report writing in nursing
- Doris M
A nursing report is a document that nurses hand over to others at shift change to let them know the patient's conditions. It can also be a report to explain something during a legal investigation. A report during the transfer of a patient to another unit in a hospital is necessary because another team will take over the care.
Some nurses refer to reports that they write to present at the end of a shift as handoff. The exchange is usually at allocation where other people will not hear a discussion about it to secure patient information.
Importance of Report Writing in Nursing
Giving a nursing report is an essential activity in nursing. It should be accurate making it necessary for nursing students to learn from school days.
- Guides patient care
- Improving patient involvement and safety
A nurse at the start of a shift may not know the health status of a patient. It makes a nursing report essential in providing essential information to an oncoming nurse about a patient to start caring. Caring for a patient without all the important information can compromise safety and care. A report during transfer of a patient from a nurse to another provides an opportunity to comprehend the details, ask questions and get clarifications for issues that are not clear. It is a reason why every nursing involved in patient care including the student nurses provide a report on the patients that they care during a shift.
Healthcare facilities might have slightly different policies for giving reports, but they all have similar basics.
Also see: Report Writing Help
A culture of safety is essential for maintaining safety in healthcare settings. It requires communication with the patient, other caregivers and family about aspects of care, treatment as well as services. A well-written nursing report achieves the original intention to ensure a safe handoff between nurses. It also allows for the involvement of the patient and family. The traditional handover of change of shift reports was at the absence of the patients at the nurse's station.
Research shows filling our reports at a nurses station makes the task to seem very guarded. Nursing reports eliminate that alone time and allow the patients to feel included by nurses as part of healthcare. Nurses are usually the first among those who take care of the patient's safety and writing a bedside report in an integral part of their care plan. A nurse is accountable for communication at the change of shift report and will make an effort to verify patient data around these issues:
- Health history
- Physical assessment
- Plan of care including the prescribed medications
At this time a patient can ask questions and set goals both short and long term with the nurse. This type of shift report helps to increase staff communication and ensures nurse accountability.
Other benefits of report writing in nursing
- Helping the patient and other people involved with the patient to understand the care
- Decreases anxiety for the patients and their families
- Decreases feeling of abandonment among families at shift change
- Increases teamwork and relationship among the nurses in different shifts and units to decrease the potential for mistakes
Report writing in nursing allows for the better provision of information about patients under the care of a particular nurse. The information on a patient in the chart records but it is more practical when it is in a brief synopsis showing situation, background and assessment of a patient.