Tips For An Organized End-of-Shift Report
Written by Joanne Potter BSN, RN
At the end of a long, busy shift, nurses look forward to clocking out to go home. Before leaving work, we must give report to the oncoming nurse. Giving report can be intimidating, especially for new nurses. It’s beneficial for nurses to learn how to give a well-organized shift report for the oncoming nurse and the patient. If you don’t learn how to give an organized report, you may find yourself thinking of things you forgot when driving home or when you’re lying in bed, trying to get those precious hours of sleep in between shifts.
If you’re a new nurse, you may find yourself getting nervous or fumbling with how to give an organized report. As with many things, you’ll learn as you gain experience. You’ll find what works best for you, what the oncoming shift prefers, and most importantly—the best way to make sure the patient is safely cared for around the clock.
I developed these tips over the years that gave me confidence to give an organized report to the oncoming nurse.
Tip #1 - Use a Report Sheet
Preparation is everything. Even if you have a great memory, don’t rely on it. Write everything down. Find a report sheet that works for you. Start with what your unit provides, as it’s usually tailored to the type of patients you’ll be working with on the unit. If you find you don’t like that one, there are hundreds to choose from online.
Fill out this sheet from the report you get when you start your shift. Throughout the shift, keep your sheet organized with the tasks you’ve performed, including all meds, labs, assessments, vitals, procedures, etc. If you come across something you’re not sure about, look it up. For example, patient Smith had an MRI last week, but you’re not sure of the results. Find the information so you are prepared to relay it to the oncoming nurse.
Tip #2 - Organized Presentation
Now that you’re prepared, you’ll be ready to give report. Start with your patient’s medical history, then move on to their current diagnosis and continue on with the flow of your report sheet.
A great way to make sure you cover everything is to go through a head-to-toe assessment. As nurses, you assess each patient every shift. This is a great strategy to make sure your report is thorough. Again, don’t rely on memory. Forgetting important information can jeopardize patient care. Use your report sheet to guide your report to the oncoming nurse.
Tip #3 - Review Orders and MAR
After going through the patient’s report, review the patient’s orders and MAR (Medication Administration Record) with the oncoming nurse. This guarantees you’re not missing orders or new orders placed since the last time you looked (we’ve all experienced those last-minute orders that sneak in, right at the last moment!). Reviewing the MAR is important to make sure all the medications on your shift have been given, and for the oncoming nurse to review all the medications and times due on their own shift.
Tip # 4 - Any Questions?
When you’re finished giving report, always ask the oncoming nurse if they have any questions. This ensures they are clear on everything going on with the patient. After answering any questions they have, confirm they understand.
Communication between the different shifts is crucial for patient safety. By giving an organized end-of-shift report, you're doing your part in reducing errors in communication. This also gives you peace of mind, so you’ll be able to go home and enjoy your time off in between shifts without feeling like you’re forgetting something.
About the Author
Joanne Potter BSN, RN is a writer that specializes in health and wellness. She has fifteen years of experience as a Registered Nurse in the NICU (Neonatal Intensive Care Unit). Her years working on the frontlines at the bedside enable her to write with a deep understanding of what patients want from their communities.
