It is the practice of exchanging important and relevant information physically and electronically about a patient (using Electronic Medical Records Review (EMR), staff, equipment and nursing activities that occurred during a shift from outgoing team of nurses/midwives to incoming team of nurses/midwives i.e. morning, afternoon and night.
Aims
· Relay patient information
· Ensure continuity of patient care
· Maintain confidentiality of patient
· Ensure accountability
Requirements
The following manual or electronic documents:
· 24 Hourly report book
· Patient’s folders
· Patient observation charts
· Ward state
· Nurse’s changes book 6. Other relevant documents (based on facility protocol)
Steps
1. Greet the nurses on duty
2. Ask for oral information on major happenings on the ward from the outgoing nurse
3. Read reports
4. Enquire about sensitive information on patients at the nurse’s station
5. Take over ward from bed to bed verifying the state of all patients
6. Establish rapport with patients during taking over, ask about their concerns and general health
7. Confirm information about the patients on charts and notes provide
8. Check with outgoing nurse if gadgets on patients are functioning e.g. cardiac monitor, oxygen flow metre etc.
9. Check on any drainage tubes if they are draining well and record the amount if necessary e.g. intravenous line, catheter, NG tubes etc.
10. Conduct inspection of ward with the outgoing nurse and note defective equipment
11. Ensure resources needed for work are available and adequate and takes over controlled medication
12. Counter-signs written ward report
13. Note important issues and document
14. Congratulate out-going nurse
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