Reports shift, transfer, incident, telephone
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Reports are used in healthcare to communicate important information about patients. There are several types of reports nurses commonly use, including hand-off reports, telephone reports, and incident reports. Hand-off reports are given during shift changes or patient transfers to ensure continuity of care. They include key details about a patient's condition, treatments, and care needs. Telephone reports are used to update other providers about significant changes in a patient's status. Incident reports document any unexpected events involving patients to support quality improvement efforts.
Reports shift, transfer, incident, telephone
- 1. REPORTING By: Mr. M. Shivananda Reddy
- 2. Report • A report is oral, written, or computer-based communication intended to convey information to others. • The purpose of reporting is to communicate specific information to a person or group of people. • A report, whether oral or written, should be concise, including pertinent information but no extraneous detail
- 3. Types of reports: Reports commonly used by nurses include • Hand off report A.Change of shift report B. Transfer report • Telephone reports • Incident reports
- 4. Hand off reports • Hand-off reports happen any time one health care provider transfers care of a patient to another health care provider. • The hand off report may be change of shift report or transfer report
- 5. • The purpose of hand-off reports is to provide better continuity and individualized care for patients. • For example, if you find that a patient breathes better in a certain position, you relay that information to the next nurse caring for the patient
- 6. Change-of-shift report Change-of-shift report is given to all nurses on the next shift • It includes up-to date information about a patient’s condition, required care, treatments, medications, and any recent or anticipated changes.
- 7. Transfer report Transfer report is given whenever the patient is transferred to other health care unit. It can happen between: • Nursing unit-to-nursing unit transfer • Nursing unit to diagnostic area. • Special settings (operating room, emergency department). • Discharge and inter-facility transfer
- 8. • Hand off report can be given face-to-face, in writing, or verbally such as over the telephone or via audio recording
- 9. • A sample hand off report format as follows: • Background information (name, age, and medical diagnosis); • Primary health problem; • Unusual occurrences; • Discharge planning issues; • Identification of significant changes in measurable terms (e.g., Pain scale); • STAT, or prn medications • Care required such as medications that need to be started, • When a dressing needs to be changed next; • Progress with interventions; and family involvement.
- 10. Telephone Reports • Health professionals frequently report about a client by telephone. • A registered nurse makes a telephone report when significant events or changes in a patient’s condition have occurred. • Nurses inform primary care providers about a change in a client’s condition; a radiologist reports the results of an x-ray study
- 11. • The nurse receiving a telephone report should document the date and time, the name of the person giving the information, and the subject of the information received, and sign the notation. • For example 16/6/15 10.35 am Mr. Sahoo, laboratory technician, reported by telephone that Mrs. Anjali’s hemoglobin is 6 gm/dl. Sign at the end
- 12. • The person receiving the information should repeat it back to the sender to ensure accuracy. • It is important that the nurse be concise and accurate. • Telephone reports usually include the client’s name and medical diagnosis, changes in nursing assessment, vital signs , significant laboratory data, and related nursing interventions. • The nurse should have the client’s chart ready to give the primary care provider any further Information • After reporting, the nurse should document the date, time, and content of the call
- 13. Telephone Orders & Verbal Orders: • A Telephone Order (TO) occurs when a health care provider gives an order over the phone to a registered nurse. • A Verbal Order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. • TOs and VOs usually occur at night or during emergencies and frequently cause medical errors
- 14. • ThE NURSE reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct • The health care provider later verifies the TO or VO legally by signing it within a set time (e.g., 24 hours) as set by hospital policy.
- 15. Guidelines for telephone and verbal orders: • Clearly determine the patient’s name, room number, and diagnosis. • Repeat any prescribed orders back to the physician or health care provider. • Use clarification questions to avoid misunderstandings. • Write TO (telephone order) or VO (verbal order), including date and time, name of patient, the complete order; And sign at the end. • Follow agency policies; some institutions require telephone orders to be reviewed and signed by two nurses. • The health care provider must co-sign the order within the time frame required by the institution (usually 24 hours).
- 16. Incident or Occurrence Reports • An incident or occurrence is any event that is not consistent with the routine operation of a health care unit or routine care of a patient. • Examples of incidents include • Patient falls, • Needlestick injuries, • A visitor having symptoms of illness, • Medication administration errors, • Accidental omission of ordered therapies, and • Circumstances that lead to injury or a risk for patient injury.
- 17. Incident Report • Incident (or occurrence) reports are an important part of the quality improvement program of a unit. • Always contact the patient’s health care provider whenever an incident happens • In the incident report form document an objective description of what happened, what you observed, and the follow-up actions taken.