Change of shift nurse’s notes. Redundant? Necessary?

[TigerGalLE, BSN, RN]

I am wondering if other nurses write change of shift nurse’s notes every shift.

Example: Bedside report received from ____. Then insert here current patient status or whatever smart phrase you have come up with for your change of shift note. 

Is this type of documentation important? Is it necessary for a court case? Is your assessment and hourly rounds enough to prove you have or don’t have responsibility of this patient? Just wondering if this is something that needs to be charted by both nurses at each shift change. 

Thanks

Tiger

[PollywogNP, ADN, BSN, MSN, LPN, NP]

Don’t see any purpose. Charting change of shift report not necessary. No need to say who gave you report since it’s the nurse on shift prior to yours. Just start with either your assessment or if you go “lay eyes” then chart time you did that with brief statement. 

[CalicoKitty, BSN, MSN, RN]

Some places do a "hand-off" thing on the chart when getting/giving report. Not a note per se. I think part of the reason is 'patient abandonment' and accountability.

[Closed Account 12345]

Documenting the transfer of care itself is not redundant. It shows the time you are no longer responsible for the patient's care and that you properly transferred the care to another nurse (no period of abandonment). This is not information that can be found elsewhere in the chart, nor can it be assumed that it aligns with shift changes (mid shift assignments, nurses running late, nurses staying 2 hours after, nurses continuing to work after clocking out despite policy, etc.).

It's also a prudent practice when heading to and returning from your lunch break.  If your patient experiences a complication, fall, meds were given late, etc., you don't want to be the one taking the fall. Many hospitals require hourly nurses to clock out at lunch, so this note shows the patient was never left without a covering RN.

Personally, I don't care to take the fall for someone else's negligence when I'm off the clock and not physically in the unit. I can remember going to the cafeteria with a nurse friend when I worked L&D. When we got back to the break room with our lunches, the monitors showed her patient's FHR had been dangerously low for several minutes with no indication of interventions on the strip. My friend went flying down the hall, and it turns out the covering nurse had been distracted in someone else's room. (As for why no one else ran to help from nurses station, who knows?)

I do feel like documenting patient status in a handoff note is redundant.  The status is readily available throughout the chart, assuming documentation is current.

"1908: Patient's care transferred to Jill, RN. Beside handoff report given. Oncoming RN had opportunity to ask questions. All questions answered." 

[LovingLife123]

I have never once documented change of shift notes or a note that I’m going to lunch.  I do not chart excessively.  I chart the things that are required of me, nothing more.  I put a chart check in at the end of my shift and the oncoming nurse completes it.  That shows the chart was reviewed.  I don’t need an additional note about it.

[JKL33]

2 hours ago, Closed Account 12345 said:

Documenting the transfer of care itself is not redundant.

Agree.

OP, I think this seems redundant because two people are charting about the same thing. In my view, though, each of the two RNs has an interest in documenting the thing that they are documenting, for the reasons already described by the member I've quoted. Also agree the patient status is the part that is redundant.

[JBMmom, MSN, NP]

I do not document a transition of care specifically. However, I do write out a short shift synopsis at the end of every shift. I know that the majority of my colleagues do not because they say it is a waste of time and double charting. However, for me, capturing the highlights of the shift in written format, because no one has time to scroll through all the pages of flow sheets to put the story together, is so important. Other than the nurse directly getting report, who may or may not record details I think are pertinent, there isn't an efficient way to pass along information. I am always glad when I find any other nurses notes, or a MD that has taken the time to write an actual note, so I can follow the progression of care and ensure I haven't missed anything.

For example, I had a patient that I charted had no right pedal pulse at the final assessment of my shift. I notified the PA and received an acknowledgement. However, somewhere along the line that PA didn't pass the info along at the end of their shift. The attending MD said that if I hadn't written the note where they saw I had mentioned it (because the nurse wasn't around when they rounded), there may have been no follow up. The patient had a blockage and required transfer out of the facility to a high level of care. Yes, I had charted no pedal pulse in the chart, but no one was going to scroll through my whole assessment to get a picture of the patient. It turned out to be an important aspect for the care of this patient. I wish people would get back to notes. 

[Hannahbanana, BSN, MSN]

One of the nicest things a physician said to me was that he could read my notes and really see what the patient was doing. That was back in the old days of actual writing, so he could identify my handwriting with a quick scan.

[sleepwalker, MSN, NP]

On 8/31/2021 at 3:13 PM, JBMmom said:

Yes, I had charted no pedal pulse in the chart, but no one was going to scroll through my whole assessment to get a picture of the patient.

Funny....always thought the assessment was the picture of the pt and, therefore, needed to be reviewed. Seems that relying on a potentially incomplete summary statement rather than a chart review would be a gate-way to errors

Just saying...

[JBMmom, MSN, NP]

1 hour ago, sleepwalker said:

Funny....always thought the assessment was the picture of the pt and, therefore, needed to be reviewed. Seems that relying on a potentially incomplete summary statement rather than a chart review would be a gate-way to errors

Just saying...

If anyone has time to scroll through the four different flow sheets and pages of assessments in order to gain the complete picture, that's great. I'm not saying my summary is comprehensive, that's not the point of it. The chart is the official detailed record, the summary note highlights where people should focus their attention, in my opinion, for changes in condition or important highlights from my shift. Maybe others don't view it that way, there's no real standard. 

[sleepwalker, MSN, NP]

2 hours ago, JBMmom said:

If anyone has time to scroll through the four different flow sheets and pages of assessments in order to gain the complete picture, that's great. I'm not saying my summary is comprehensive, that's not the point of it. The chart is the official detailed record, the summary note highlights where people should focus their attention, in my opinion, for changes in condition or important highlights from my shift. Maybe others don't view it that way, there's no real standard. 

I agree with you...in principle. Unfortunately, I've found that way too often what should be highlighted and brought to focus is not... and there lies the problem. Those with weaker assessment skills, less knowledge, or whatever will often not recognize what should be a focus of attention or highlighted. Better to take the time to review the most recent assessment, vitals, provider visit notes, etc. to gather an overall picture of the pt yourself to assist/guide future care

just my 2 cents

[Sour Lemon]

I clock out, they clock in. I stop charting on the patient, they start charting on the patient. The patient is "assigned" to me until 07:30AM, assigned to them at 07:30AM, and blah blah blah.

The only time I chart about handing over care is when I transfer a patient off of my unit. In those cases, I think it's important to make it clear exactly when the receiving nurse took over. 

If something urgent occurs with a patient on my unit while I'm in the process of leaving, I'm going to stay and make sure that it's handled whether I've given report yet or not. For the record, I mean something like a code. If someone pulls their IV out at 07:30, I will wish you good luck in starting a new one.