end of shift report

Published

Hello,

I am a very new Nursing Coordinator for a very new acute Inpatient Rebabilitation Center. Our unit has been open since Aug 3 and I have been here 3 days. Before I was hired, there was no nursing leadership, only the Program Manager, who is a PT.

I will start by saying that I am not a rehab trained nurse, and unfortunatly, we have only one out of 20 of our nurses that have worked in rehab previously.

Because there was really no one to do bedside training for the RN's (besides the consultants who helped open the unit and they did very little "How to be a Rehab Nurse" type things") they have fallen back on what they know, which is acute care.

As a first step in the process of pulling them toward more rehab nursing, I thought I would start with end of shift report. My thinking is that if they give each other the correct information they are more likely to start thinking that way and be more able to have better teamwork with the therapy staff.

I am hoping that someone would be willing to share their end of shift report template, or share what is on yours besides the normal physical assessement.

Thanks very much.

Up Vote Up Vote ×
Specializes in Geriatrics, acute hospital care, rehab.

We keep our report as brief as possible. We include the following in our shift report. 1. Pain, 2. Transfers (how much assist pt needs) 3. ADL's, 4. Abnormal labs and VS, 5. Pt. teaching needs, 6. Bowel & Bladder issues, 7. Safety precautions (ie fall precautions) 8.Skin integrity issues. We don't pass on any unnecessary info such as the info on the kardexes or info the nurse can find in the computer. After the on coming shift listens to report they are to come find us if they have questions and to check for any updates.

Up Vote Up Vote ×
Specializes in ICU, Education, Peri-op.
We keep our report as brief as possible. We include the following in our shift report. 1. Pain, 2. Transfers (how much assist pt needs) 3. ADL's, 4. Abnormal labs and VS, 5. Pt. teaching needs, 6. Bowel & Bladder issues, 7. Safety precautions (ie fall precautions) 8.Skin integrity issues. We don't pass on any unnecessary info such as the info on the kardexes or info the nurse can find in the computer. After the on coming shift listens to report they are to come find us if they have questions and to check for any updates.

Thank you, this is helpful.

Up Vote Up Vote ×
Specializes in inpatient rehab (general, sci, tbi, cva).

The biggest thing for rehab, no matter where you go, is usually bowel, bladder and skin.

As long as you cover those in your report you should be good. Our rehab hospital uses the patient care profile to do report. Most everything is on there.

We also verbally pass along anything unusual (pt likes or dislikes, IV times, labs drawn and results if available, etc.)

Up Vote Up Vote ×

I work the night shift on a rehab unit, and I like to know how the pt transfers, if they are incont or involuntary, what went was said on staffing day, expected discharge date and the goal. With diet I want to know if they are on honey thick or nectar thick liquid.

We have a tool called the SBAR if is a form that is broken up to Situation, Background, Assessment, and Recommendations. I fill these out at night and they can be used to give end of shift report.

Up Vote Up Vote ×

So do we also have a SBAR for end of shift report. we use to give each others copies after our report but most nurses now don't and want to make their own report copies just for them. What ever works. But I like rehab you get to meet so many pts that come in and help them nursing and social wise which they also need. Cause many get board with no one to talk to. Someone that cares means the world to them. Don't ya think?

Up Vote Up Vote ×
Specializes in Oncology.

I use the RN Report Card it's a great end of shift report i've been using it since May.

You can find it at http://www.rnreportcard.com

Up Vote Up Vote ×

I was having a similar problem. I've been working for 3 months now and had the same issue.

Jumping into a job right out of school was a shock to me. I posted a question about shift reports and got about 4 response with minutes.

I got sent a few templates and was forwarded to a website http://www.rnreportcard.com. I tried the templates but all in all the RNReport Card worked out the best for me.

Up Vote Up Vote ×
+ Join the Discussion