SHIFT

REPORTING
 Reporting
Reporting or Endorsement is a hand-over
(or hand-off) communication between
units and between and amongst care
teams.
This relates to the process of passing
patient-specific information from one
caregiver to another, from one team of
caregivers to the next, or from caregivers
to the patient and family for the purpose
of ensuring patient care continuity and
safety.
• Hand-over communication also
relates to the transfer of
information from one type of
health-care organization to
another, or from the health-care
organization to the patient’s home.
Endorsement Settings

1. Admission from primary care

2. Physician sign-out to a covering
physician
3. Nursing change-of-shift reporting
4. Nursing report on patient transfer
between units or facilities
5. Discharge of the patient back
home or to another facility.
Change-of-Shift Reports
It is given to all nurses on the next
shift to provide continuity of care
for clients by providing the new
caregivers a quick summary of
client needs and details of care to
be given.
Key Elements of a Change-of-
Shift Report
1. Shift reports should take place in an
area that is private and free of
interruption to maintain client
confidentiality.
2. Follow a particular order such as using
the room number of the patient.
3. For new clients, provide the reason for
admission or medical diagnosis,
surgery (and its date), diagnostic tests
and therapies in the past 24 hours
Key Elements of a Change-of-
Shift Report
4. Include significant changes in the client’s
condition and present information in
order.
5. Provide exact information. Eg. “Mr. Jones
received Morphine 6 mg IV at 7 pm.”
6. Report client’s need for special emotional
support. Eg. Newly diagnosed cancer
patient scheduled for a surgery and
needs time to discuss his feelings before
preoperative teaching
Key Elements of a Change-of-
Shift Report
7. Provide summary of newly admitted clients,
including diagnosis, age, general condition,
plan of therapy, and significant information
about the client’s support people.
8. Report clients who have been transferred or
discharged from the unit.
9. Clearly state priorities of care and care that
is due after the shift begins.
10. Be concise. Don’t elaborate on
background data or routine care.
 Telephone Reports
Reporting about the client by telephone to
inform primary care providers about a
change in a client’s condition.
This should include the following:
1. Client’s name
2. Medical diagnosis
3. Changes in the nursing assessment
4. Vital signs related to baseline vital signs
5. Significant laboratory data
6. Related nursing interventions
 Telephone Reports

Factors to be Considered when receiving

and giving telephone reports:
1. The nurse receiving the 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..
2. The person receiving the information
should repeat it back to the sender to
assure accuracy.
3. When giving a telephone report to a
primary care provider, it is important to
begin with giving the name and
relationship to the client.
4. After reporting, the nurse should
document the date, time and content of
the call.
Telephone/ Verbal Orders
A Telephone/ Verbal Order is a
doctor’s order through telephone
or by telling the nurse directly to
convey necessary information in
the treatment and management of
a patient.
Guidelines for Telephone and
Verbal Orders
1. Know the agency’s policy regarding
phone orders.
2. Ask the prescriber to speak slowly and
clearly.
3. Ask the prescriber to spell out the
medication if you are not familiar with it.
4. Question the drug, dosage or changes
if these seem inappropriate for the
client
5. Write the order down or enter into a
computer.
6. Read the order back to the prescriber. Use
words instead of abbreviations.
7. Write the order on the physician’s order
sheet. Record date and time and indicate it
was a telephone order (TO). Sign name and
credentials.
8. When writing a dosage, always put a
number before a decimal but never after a
decimal.
9. Write out units.
10. Transcribe the order.
11. Follow agency protocol for signing
telephone orders (eg. Within 24 hours)