Report writing is essential in any profession, and since nursing is also considered a profession, one must record their work after shift completion. A good nurse report should contain the following details: patient history, diagnoses, vitals labs, medications, and more. Nurses must show accountability for their work and duty to the patient by writing a proper report. An excellent report ensures continuity of care. You are likely to compromise the health and safety of a patient if you don't fill out all the important details. According to studies by John Hopkins University, medical error is the third leading cause of death in the US. For this reason, it's important to know how to write one correctly.
This guide will show you how to write the perfect nursing report.
Also known as an end shift report, or a nurse brain, a nursing report is a compilation of all important patient details written by a nurse at the end of a shift. It highlights the record of a patient's medical background, situation, treatment, and care plan. This report helps in facilitating handoffs. For instance, a nurse coming in for their day shift would get a report from the nurse finishing their night shift.
Writing a good nursing report ensures a seamless handover to the incoming nurse who may not be familiar with the patient and their needs.
These reports also go with a patient being transferred to another hospital or department, for instance, if the patient is being transferred from the ICU to the recovery room.
Please keep in mind that nursing reports should be made promptly if they are to serve their purpose.
A nursing report shows the patient's current medical status. When writing one, there are essential things that you should include. These things are,
Basic information:
Current patient health details
Ongoing patient care information
These details are essential; providing them to the incoming nurse helps them keep track of the patient.
Other types of information you will likely see on a nurse report include:
You need to organize the process well to develop an efficient report that won't raise any issues. You must also write it on time to provide the patient with safe and high-quality service.
Follow these steps to fill out your nursing report:
Before completing the report, you must understand its importance and the application area. This way, you will intelligently communicate the information. Remember that reports not supported by facts are considered useless and worthless.
The SOAP method is the order in which the medical note is written, and it follows the following plan: Subjective, Objective, Assessment, and Plan. It's vital to arrange your information in the following plan for a professional view.
Nurses use the SOAP method in their reports to make writing easy for others to understand.
Begin by filling the template with essential information like the patient's age, sex, date, and time. Include your knowledge as well.
Note that you should not review any routine care procedures now.
Once you have filled in the basic information, collect subjective details from the patient. This information is limited to the knowledge and perspective of the patient or family member accompanying them. Pay attention when you are given this information, especially what they report about their symptoms and past diseases.
Some of the information you will collect about the patient include the pain points and level, the purpose of their visit, and any other concern they might have about their health.
Also, provide any other healthcare problems and diagnoses. Make sure you compare this information to the patient's age.
When collecting this information, you must remain calm and show some level of compassion. You should also be patient, especially when dealing with difficult patients or family members.
After collecting all the subjective information from the patient and family members, you should gather objective information. Objective information is that which supports subjective details. Including this information is necessary because it will lead to the patient's diagnosis. Objective information includes the patient's blood work, vitals, observable symptoms, and any tests ordered by the attending doctor.
Also, include any observations you've made about the patients' health and responses. Ensure you stress any recent changes but don't include critical information about the patient's behavior.
Assessment involves sorting and analyzing the information provided to learn more and make an informed decision about the patient's health, care plan, and current decision-making.
Jot down the conclusions based on the objective information collected and the conclusion made by the primary care physician. Additionally, include the prescribed medication and how the patient responds to it. Also, note any changes the patient has shown since being administered (are their symptoms improving or worse?)
A lack of assessment can pose a risk to the patient, so you must include this section.
Related: How to write a nursing diagnosis (NDx)
A care plan section outlines the needs and wants of the patients and any interventions you make to meet them. For instance, if the patient needs a lab or imaging test, include it in this section. Also, ask how the patient is responding to the care plan. If, for example, you advise the patient to return to the hospital for a checkup and they fail to show up, include it in the report.
You should write this section well because it will help show the plan's effectiveness. It also acts as evidence that care was given to the patient.
Interventions are actions you take to help the patient achieve their expected outcomes. This section can include different types of information, including physical treatments, emotional support, and education given to the patients about their ailments, medication, and current or future treatment. Also, include details such as when you gave the patient their medication.
When filling out a nursing report, you must remember that you are not just writing; you are also communicating. Another nurse or doctor will use your report to decide on the patient's care plan.
As such, nursing reports should be easy to read. Use the following tips to help you write a perfect report.
If you don't understand how to write the report or which direction to take when asking for information, ask for help. It's not shameful or embarrassing to confess that you don't understand how to fill some sections. Most hospitals and doctors use the SOAP method to write nursing reports, but some offer templates. If you are working in a new hospital or clinic, ask for help from your supervisor. You can also delegate the task to an online nursing/medical report writing service like ours.
Remaining objective as you collect and fill out the nursing report is important.
To be objective is to be unbiased; when you are, it means feelings do not lead you. When collecting data, use your senses: hearing, sight, smell, and touch, to assess the patient. You will collect this type of information during a physical examination.
When you remain objective when collecting this data, you will keep the progress report accurate and precise.
Instead of passive voice, use active voice because it is direct. Active voice involves writing sentences with the subject performing the action. Using an active voice in your report will bring clarity by stressing to the reader who is taking action.
Active: I administered 500mg of paracetamol to the patient.
Passive: 500mg of paracetamol was administered to the patient.
The problem with passive voice is that it leaves important details out.
Don't write unnecessary information. You have to find a balance between being detailed and concise. Being concise involves providing as much information with as few words as possible. Rambling around in your report will not serve any purpose but only create confusion. Also, you don't want to include unnecessary information that will make it harder to follow the report. The best way to ensure your report is okay is to use the provided nursing report template.
No matter how casual you are with your colleagues or supervisor, it would help if you left this during breaks or outside working hours. You must be professional when writing a nursing report or any other kind of report. You must approach patients to understand their concerns, fears, symptoms, etc. This means that your listening, verbal, and nonverbal verbal skills should always reflect a level of professionalism.
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While speaking to the patients and gathering the information, it is important to use an outline and fill in the details later. Finishing consultation ensures you give your all to the patient and what they say. You should also attend to one patient and write the report before proceeding to the next patient because it will help you remember the notes more clearly. However, if you can't finish the notes before attending to the next patient, you should write the most important details first.
Over time, each nurse will develop their voice in the reports. Reading how other nurses, exceptionally experienced ones, have written their reports will help you develop your skill and see improvement areas. Getting inspired by sample nursing or medical reports is a great way to write the best one.
Since a nursing report is given at shift changes, you must be as straightforward as possible. For instance, if you discover a pain relief measure that is effective on the patient during your shift, including the information will ensure the next nurse continues with the same pain relief measure.
Also, if there are procedures that should be conducted as soon as possible, include them in the order they should be done.
Please take note that a nursing report aims at ensuring continuity of care. If your text cannot be skimmed, it defeats its purpose. All the information in the report is sensitive, and if you make a mistake, it will have severe consequences for the patient.
When writing the report, write every word, phrase, and sentence well. Also, use the right medical terminology. This way, you will show not only authority but also credibility.
Late entries are any information absent in the original entry recorded after writing the original report. The problem with late entries is that they tend to introduce inaccuracies. If you must introduce a late entry, ensure you follow the hospital's or clinic's policy on going about it.
Remember that constant late entries will portray you in a bad light.
If you consulted any physician while caring for the patient, include it in your report. For instance, if you consulted a gynecologist or oncologist concerning any symptoms the patient was experiencing, mention it in the report. Write them down, starting with their names, titles, times, responses, and resulting actions.
Even though the use of the medical abbreviation is not a new thing, care should be taken when using them. It's easy to make mistakes by inappropriately using abbreviations. If you have to use abbreviations, ensure they are approved by the facility you work for.
Hearsay or personal statements will carry less weight on the paper. Only write details that are supported by facts. If you have to write personal opinions, use quotations to show them.
Also, be honest in your report, especially when you've made a mistake. Honesty won't always protect you against consequences but will preserve your reputation and moral code.
Now that you know how to write your report, here are some common errors to avoid.
Knowing the kind of medication that a patient is taking or those that they are allergic to is critical to their care. Always specify every medication they take, the dosage amount, and how the patient reacts to them. In the same manner, knowing that a patient is allergic to penicillin or other antibiotics is the difference between treating them with the right medication or causing more health problems.
Omitting drugs is wrong, but leaving important sections blank is worse. The incoming nurse expects to find a well-written report to help them continue caring for the patient. If you haven't done this, how will they go on? Blank spaces create ambiguity. Did you leave it blank because treatments weren't administered, or you forgot to write the treatment?
There is such a thing as too much unnecessary information in nursing reports. The aim of these reports is to document the crucial facts that can help with patient care. There are things that you shouldn't put in your report because they are irrelevant, or the next nurse can quickly look up and understand.
Writing unnecessary information will take too much of your time, which you could use to write the next patient's report. Such information includes:
Using your judgment when writing this is essential to avoid wasting time on unnecessary details. When in doubt, you can always consult your supervisor.
Report writing is a crucial part of the nursing routine. A nurse's reports help registered nurses stay organized and capture all the important patient details like diagnosis, vital signs, allergies, pain management plans, and more. Providing this information ensures the next nurse does not risk the patient's life by making mistakes such as failing to prescribe the right medication. The above tips should help you write the perfect nurse report if assigned one as a nursing student.
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