End of shift report

SBAR shortened. Why the patient came in, any pertinent background (said in a sentence or two--the rest can be looked up), any abnormal assessment findings that the nurse should be aware of (again, briefly-- only the things that may need to monitored closely during their shift), and any recommendations for things to do for the next shift, only if it wouldn't be readily appearant from the report discussion.

Other things-- like outputs and ambulation status I only put in the written shift summary to be looked up.

It's going to depend a bit on what kind of unit you're on, but my report typically follows this format (and I've created my "brain" sheet in this order):

Patient name, age, sex, date of admission, code status

Principal diagnosis and any relevant medical history

Telemetry Y/N and any funky rate info (we're a cardiac floor)

IV location(s) and fluid/rate or locked status

Diet, Accu-checks

How the patient ambulates/transfers/toilets (briefs, Foley, bedpan, bedside commode, standby assist, etc.)

Patient's living situation (home with spouse, LTC facility, homeless) and what the discharge plan is, if any (back home, or to a SNF or rehab facility, etc.)

Any upcoming procedures

Any emotional / psych / family dynamic info

Any funky physician orders

On an icu we give a good, detailed report. Especially if it's the first time a nurse has cared for this patient. If it's not, I give updates. But it goes something like this:

Name, age, allergies, and docs following

Pt Hx

reason why pt is here

neuro

cardio

resp

gastro

gu

access

abnormal labs

drips and rates

anything that needs to be done

Thank you for the suggestions and examples. As a class we have worked with SBAR some so I should be able to implement that suggestion easily enough. The "brains" are a great, and I will be printing those off to implement during clinicals. Thank you all so very much for taking the time to answer my question. Blessings to you all.

Depending on the facility, you can print off a rounds report. That sheet has the pertinent info that you will need to make it through your shift, and giving report. You can write on it as you go along. I know others who create their own sheets, and follow SBAR. I like our system, as it takes two seconds to print off and has everything there.

Thank you for the great suggestion. I will check with my preceptor to see what the facility has available. Blessings.