Updated: May 13
Hey everyone, looking for some input on your end of shift note. I'm a second year nursing student and I struggle with this. Each of my clinical instructors have had different requirements for it, and of course each facility I am in has a different EMR which makes it different as well. But overall I am left with a void on what I should be noting there when I'm out in the real world. I've read some articles on it and they would have you list everything, no matter how insignificant which seems impractical as no one is going to read your 5 paragraph "summary" of your shift. Some of my instructors have had me write SOAP or DARP notes but I don't see that being done by the RNs in the facility. So what is it that you put in your end of shift note? Thanks!
Kenneth Oja, PhD, RN
Smart move in doing a little research and learning the different methods in which you can write your end of shift note because it's going to vary by facility and type of unit / department.
What's consistent across facilities is that a nursing end of shift note is a communication tool to update the oncoming nurse about the patient's status and any changes that occurred during your shift. They're important for continuity of care and making sure that everyone involved with the patient's care is aware of any relevant information.
The ANA's Principles for Nursing Documentation is a good resource.
Other things to consider include:
Also, you're still learning and that's OK! It takes time and practice to find the right balance between including all relevant information, being concise, and following the guidelines for a specific facility or unit.
River&MountainRN, ADN, RN
I'm going to be approaching this from a different angle than what you are currently learning in, since I'm in home care, but the principles are the same:
-Status of the patient (where they are-in bed, in chair, etc; respiratory status; cardiacs status; etc)
-Any major deviation from baseline, whether it is acute or expected to be chronic (my patients are usually on a downward slide and may or may not rebound), and how it is being addressed and who was made aware
-Needs that are pertinent/will carry over through the next shift (the most recent example in my own work that comes to mind is: patient continues with loose stools, requiring more frequent diaper checks; patient continues to show poor signs of safety awareness, continuous cueing and redirection required)
-Upcoming appointments/specialist consults that the oncoming shift should be aware of
-If on an off shift, requests from family (or others) that need to be addressed during "normal business hours"
I work geriatric psych so the medical status, as well as the behavioral status, of the patients vary from euthymic to quite intense. We are not required to do end of shift charting.
I don't care for the button-clicking computer charting, so if a patient's status has a wide variation from the norm, I do quite a bit of narrative charting as the shift progresses.
This approach has prudently proven beneficial, in that the last narrative note is typically that of an end of shift note.
Otherwise, the button-clicking charting is sufficient.
We don’t do end of shift charting. It’s double charting. Everything needed should be in your boxes that you click. Having to put it in a note is redundant.
The only time I physically chart notes is to communicate that I contacted physicians over lab results or changes in my assessments. The change in my assessments appears in my charting but then I type a note as to who I notified, time, and orders received.
Since this is nursing school you will simply have to write a note per your instructor’s instructions. But you shouldn’t need to do it in the real world. I know some nurses still do it, but like I said, it’s redundant to do so.
NightNerd, MSN, RN
I don't write notes unless something out of the ordinary occurs, whether it's a behavioral event or a medical situation. Your charging is supposed to cover any "normal" findings or activities during your shift. A wise former coworker told me, "The less you chart, the less you'll hace to reconstruct in court, God forbid you get put on the stand." Obviously you need to account for and remember certain things, but overcharting is tedious and doesn't really help you.
I do know nurses who will write a note after doing their assessment and med pass, such as, "Assumed care of pt at 0700. Report received from NightNerd RN. Physical assessment as documented. VSS, pt in no apparent distress. Will continue to monitor." Nice short little note to say you were there. Probably nothing wrong with adding that if you want to.
To get through school, just do what your instructors ask and look forward to days of much less writing! Writing is definitely an important skill and they are trying to teach you to be detailed, which is necessary; you'll just find in your practice that all of these lengthy notes may end up being redundant.
Jeniele, ADN, RN
Thanks everyone for your advice, I appreciate it!
I think of it this way: when I come on duty, what would be helpful to know quickly without wading through pages of checked boxes?
I would likely say something like: POD 2. Amb ad lib. Reg diet tol. No BM yet. Anticipate d/c tomorrow; teaching begun.
Others might disagree with this for a lot of very good reasons. But if your shift is chaotic from the beginning, getting a quick snapshot like this will help you prioritize. For school purposes, it is whatever that particular instructor wants.
Create well-written care plans that meets your patient's health goals.
This study guide will help you focus your time on what's most important.
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