You probably enrolled in nursing because you are not the type of person who would like to sit behind a desk all day and drown in paperwork. But newsflash! Paperwork has become a huge chunk of nursing.
Among all the never-ending charts, there is one which is the most crucial. The Nursing Report. It encompasses all your day’s work. And remember, if you didn’t chart it, you didn’t do it! So, it is crucial to fill out the nursing report well.
While every hospital will have a different template, here are a few tips that should help you in completing the nursing report in full.
1. Start the Nursing Report with Patient Details:
Patient’s name & surname
ID number
Allergies
Ward name
Bed number
Consultant/ Medical Firm
Diagnosis
Pro-tip: Update the diagnosis! While a patient might have presented with abdominal pain 5 days ago, she might have had an appendicectomy. So, update the diagnosis and don’t copy yesterday’s report.
2. Information about the patient’s activities of daily living:
Whether it is checking boxes or writing, make sure that your nursing report includes information about the patient’s cognition, bathing, mobility, and bowel movements.
3. Breathing:
Specify if the patient requires breathing assistance, if so, which mask and what rate? You should monitor this along with the parameters. Make sure to understand The Importance of Monitoring Parameters
4. Skin:
Mention any bruises/ulcers/surgical incisions that the patient has. Write in detail how you cleaned it and what dressings you used, as well as when it is next due.
5. Nutrition:
Specify if the patient requires assistance in eating and mentione any dietary restrictions. Common diets will include: clear fluids/ liquidised food/ soft food/ diabetic diet/ gastric diet/ normal diet etc.
6. Patient’s general condition:
Write down how you found your patient (rested in bed/ short of breath/ anxious).
7. The doctor’s plan:
Write down the important points from the doctor’s plan and whether it was completed along the day.
8. Upcoming appointments:
Always make a note of any future tests and reviews such as imaging tests, scheduled procedures, outpatient’s appointment, or any other reviews.
9. Any noteworthy happenings during the patient’s day:
While you don’t need to list the small details like when you found your patient smelling his armpits, you should make a note of patient complaints. These may include any pain, discomfort, nausea itching etc.
Pro-tip: Make sure to follow this note with the action taken, and how it was resolved
10. Pending items:
Before closing off your report, specify any pending bloods/scans/reviews, or anything that you would like the next nurse to monitor.
11. Finish off the Nursing Report by Signing:
Close off the report by writing your name, and signature.
Congrats! You have now completed a full report ? Did you enjoy reading this? Make sure to checkout some of our other articles!
Don’t like to read, we have you covered! Checkout my YouTube Channel NurseMiriana
And make sure to follow me on my Instagram Account Nurse.Miriana for the latest updates!
