The outline for a gold star bedside shift report

Stories - Mighty Trophy PNGShift to shift report has gone through several changes in my ten year career as an RN on a busy neurological floor in a level one trauma center.

While in nursing school, the tape recorder method was used. Nurses from the night shift reported off in a taped recording method for the oncoming day shift RN.

This was time consuming and costly.

As a new grad, the paper method was used. Nurses sat in the back room and wrote out report for the next shift.

The patient was not involved, labs, vitals, notes were not looked up in the computer and questions were not readily asked or answered.

Through research and recommendations, the bedside shift report has come into practice which gives both outgoing and oncoming shifts the opportunity to talk, look up labs and other important information, and the patient is included in the dialogue.

The bedside shift report if done well, gives a better sense of communication between nurses, patients, and their family members.

Key elements to the bedside shift report are: background, current assessment, and pertinent information needed in order to best care for the patient during the shift.

Background elements should include past medical history and what currently brought the patient to the hospital.

For example: Mr. Smith is an 85 year old man with NKA, DNR with PMH of HTN, HLD, DM 2 and AFIB who was found down by his wife last night.

He is here for a stroke work up. He had an MRI in the ED and is waiting for his ECHO, and CT angio of his head and neck.

Currently he is NPO for fasting labs and after that we’re waiting for speech to evaluate his swallowing as he does seem to be having trouble with his secretions. He was taking a general diet prior to this hospitalization.

At this point, the outgoing and oncoming nurse can go into the room to meet Mr. Smith and his wife, to do a modified stroke scale on the patient, assess pain and ask what are the goals for the patient in the upcoming shift. They can also check out the IV for infiltration, double check on IVFs, check oxygen rate and 02 status.

At the bedside, the patient will be informed of today’s tests, what to expect and the nurse will assess how he ambulates, how he voids, what he’s eating and if he has pain.

Questions can be asked and answered

The patient feels satisfied because he is being kept in the loop about his care and the oncoming nurse feels she has a handle on what she needs to know for the shift.

If there is a change in patient condition this can be assessed during bedside shift report as well. The doctor can be paged and interventions implemented.

There is less risk of missing something when two sets of eyes are assessing the patient’s condition.

All in all, the bedside shift report is a concise, effective way of communicating pertinent information to the next shift – enhancing patient care and staff and patient satisfaction.

It is one of our most important tools and hopefully we don’t take it for granted.

, ,

Skip to toolbar