Careers

7 Essential Things You Should Include in The Nursing Report Sheet

Any kind of profession deals with reporting, especially if you work as a nurse. In reporting, a nurse must create a nursing report sheet. Most people don’t realize how important the nursing report is. For medicals, nursing reports have an important role.

Why Do We Need a Nursing Report Sheet?

Why does the nursing report hold a primary role in medics? You can imagine without any records of patients, diagnosis, medicines, it will mess up the sequences of treatments given to patients. It has a high chance to mislead the doctor as well.

Normally, nurses work in shifts. Once a nurse already ends the shifts, another nurse will replace her role. The nurses who have wrapped up their shifts, have to hand over the nursing report to the nurses who will start the next shifts.

So, the nurses who work at the next shifts will know what to do to the patients after they received the nursing report from nurses in the previous nurses. The main job of nurses is taking care of and monitoring patients.

Fundamentally they are just human and need a rest, so they cannot stay by patients’ side forever. Hence, they work in shifts to get the proper rest that they deserve. On the other hand, safeguarding patients must be continual. That is why the nursing report comes in handy.

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What is The Nursing Report Sheet?

In essence, a nursing report means a written or verbal data containing information about patients’ health status, responses, outcome, treatment. The report sheet definitely will help other medical staff to make a clinical decision, coordinating team members, and continuity of care.

Things You Should State in The Nursing Report Sheet

All the information about patients must exist in the nursing report sheet template. There are standard templates of nursing reports that will help you organize the information efficiently. A good nursing report must include the following things.

Current Medical Status of Patient

The nurse has to monitor the patient’s condition. The main point of reporting is to let the other medics continue the treatment toward patients. In this case, you should take note of the current status of patients’ health.

For example, a nurse takes care of a patient with a high fever. They need to measure the temperature and give paracetamol periodically. In the next 4 hours, he or she must check whether the temperature is still high or not.
Unfortunately, his/her shift ends before the time to check the temperature comes.

So, she/he needs to state the current condition of patients in the report sheet. It will lead the nurse in the next shift to decide if it is necessary to give paracetamol again or not.

Medical History and Medication Needs

When patients come to the healthcare centre or hospital, it is important to ask about their medical history. It could be the key to make an accurate diagnosis, especially an acute illness. In addition, it helps to determine the right action in order to lower the risk of illness.

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All patients require different medication depending on the illness they suffer. A good nursing report sheet must provide the details of medications that patients require. It will help doctors to give an evaluation of medical treatment as well.

Allergies

One of the basic questions to ask the patient is whether they have allergies or not. It helps doctors to prescribe medicine that will not cause allergic reactions. Without allergies information on the report, it might cause a wrong medication resulting in a serious condition to the patients.

The Pain Level of Patients

Is it really necessary to include the pain level of patients in the report? Yes, it is very crucial to assess whether the disease improves or deteriorates. It also determines whether the treatment given works or not. Eventually, it helps doctors to figure out the best treatment.

Discharge Instruction

Once the patients’ condition has improved and doctors allow them to discharge from the hospital, usually, there are some instructions to follow by patients. These instructions contain important things to manage patients’ self-care.Attending Doctor

Most nurses usually take note of the doctor who attends the patients. It enables her to report directly to the attending doctor regarding patients’ health status. They also put the result of consultation with the doctor on the nursing report.

Lab Results

In order to ensure the diagnosis, some medics need to have a lab test. Aside from the basic details of patients, nurses must include the result of lab tests as well. The lab result in the report will help the doctors to deduce the diagnosis, monitor disease, and plan treatment.

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Benefits of Nursing Report Sheet Templates

There are many advantages of putting detailed information regarding patients in a nursing report sheet. Most nurses regard this report as their brain. Without this, they will panic and worry to mess up while attending to patients.

Function As A Shortcut To Patients’ Information

All details regarding the patient’s current medical status, allergies, medical history, treatment, and such are available in one sheet. Even when a doctor asks about INR or the International Normalized Ratio of patients, you can just open the nursing report to answer.

Help To Record All Things To Do Before The End Of Your Shift

With the help of a nursing report, you can list all things that become your responsibility. Make sure those things are accomplished and delegate some tasks to nurses in the next shift.

Enable You To Distinguish Each Patient

When you attend to more than 5 patients with different medical histories and diagnosis simultaneously, it is hard to recognize each patient without a nursing report on your hand.

Keep the Charting Accurate

If you take note of everything in the nursing report properly, it will make the charting more accurate. The accuracy of charting or record is crucial, especially the nursing report sheet ICU which must include every single thing regarding the patients in critical condition.

Becoming a nurse doesn’t merely provide medical treatment toward patients, but they need to do administrative work like creating a nursing report sheet. All things you do next absolutely depend on what lies on the nursing report.

Noah Chapman

Hello, Im Noah Chapman. Im Editor And SEO analysis for Cambridgehack.com. Im a man with 3 beautiful angels towards me. That my beautiful wife, and two beautiful daughters.

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