Nursing

ReportD-III Keperawatan
STIKes Muhammadiyah Ciamis
Group 2 (3B)
Amira Levi
Dita Siska
CK
Fuja
What is a Nursing Report ?
 Nursing Report
Nursing report is given at the end of the nurses shift to another nurse that will
be taking over care for that particular patient. Nursing report is usually given in
a location where other people can not hear due to patient privacy.

Reporting is one component of nursing documentation.

Reporting provides a summary of the activities on the observations seen, made or
heard. With reporting, the nurse can communicate information about the client
so that all team members can make the best decisions about the client and their
care.
Kinds of Nursing
Reports...
0 Task Exchange Report 0 Phone Reports

1 To provide better
2 Communication using the
telephone is often
continuity of care required by members of
among nurses who the nursing team as a
care for clients medium to convey

0 information

3
Client move reports
That is when patients are
0 Accident Report
transferred from one unit
to another to get a
4 Accident reports can help
identify high risk trends in
different level of nursing nursing care or the daily
activities of the unit that
need improvement.
How Do You
Write a
Nursing
Report ?
 Write a Nursing Report
1) AssessmentAssessment is the initial stage and the main
basis of the nursing process
2) Nursing DiagnosisNursing diagnosis is analyzing
subjective and objective data to make nursing
diagnoses.
3) InterventionA nursing action plan is a series of actions
that can achieve each specific goal.
4. ImplementationImplementation is the processing and
embodiment of the nursing plan that has been compiled
at the planning stage
5. EvaluationEvaluation refers to assessments, stages, and
improvements. At this stage the nurse finds the causes
why a nursing process can succeed or fail
How Do I Write
Good Nursing
Shift Report ?
Write Good Nursing Shift
Report
At the end of the task, the nurse reports imformation
about the client for whom she is responsible to the
nurse who works on the next shift, the goal is to
provide better continuity of care among nurses who
care for the client, complete reports upholding the
nurse's accountability in the belief that client care is not
interrupted
Written by nurses who are wrapping up their shifts
and provided to those nurses beginning the next
shift, these details should include :
• a patient's current medical status, along with his
or her medical history, individual medication
needs, allergies
• a record of the patient's pain levels and a pain
management plan
• as well as any discharge instructions. Without
these details, a nurse could potentially
endanger a patient’s life.
How Do You Give A Good
Hands Over In Nursing ?
Give A Good Hands Over
In Nursing
1. Nurses must also communicate well with patients
2. Nurses are required to be able to provide information to
patients about their health conditions, disease prevention,
and other health improvement efforts
3. Nurses must also be able to be involved in counseling
patients and their families to determine patient treatment
Nursing care is a series of interactions between nurses and
patients and their environment in order to meet patient needs.
Some things that are included in nursing care, for example, are:
● make the bed
● adjust the patient lying position
● Measure body temperature
● bathe the patient
● Change the wound dressing
● Apply a compress
● Give medications according to a schedule. etc
Thank You For
Your Attention 