End of Shift Duties & Notes
Oncoming nurse what do you say?
In order to wrap up your shift successfully, you need to do a final sweep of your room, orders, patient status, and a good nurse note. In this episode, we cover all end-of-shift duties.
When we first started nursing, there always was anxiety properly wrapping up a shift. Questions always ran through the mind of what else:
- What is my patient’s status?
- Did I empty all my drains (foley, chest tube, Jp’s, canisters)
- What are all the orders for the patient, are there new ones?
- Should I give that 7:30 med?
- Did I write a note for my patient?
A usual report is around 5-15 minutes per patient depending on specialty. One of the most frequent errors during a shift report is omitting critical safety information. Sometimes you can use different colors on your report sheet to highlight the important information.
1. First things first
Never forget that the patient is your first responsibility. They trust you to keep them from harm. Be positive, sincere, honest, and gentle with them and anyone else you encounter, for that matter. Smile.
2. Tidy up your room
Prior to 730 make sure you do some housekeeping in your room. Did you empty out all your foleys and drains? Did you turn your patient? Last-minute bowel movement check. Organize all your supplies in your room(s).
3. Giving end of shift report
An end-of-shift report is a detailed report of your patients and their overall care and medical status. End of shift reports includes medical history, recent procedures, lab values, medications, head-to-toe assessment, pain management, and plan of care.
What should be in your nurse to nurse end of shift report:
- The patient’s name and age
- Code status (Full/DNR/Partial)
- The Isolation precautions
- The patients admitting diagnosis
- Most relevant history and other diagnoses
- Consultation – Doctors on the case
- When the patient came in and change events with dates
- Review of systems with important/abnormal assessment findings
- Skin – wounds or pressure injuries
- Sugar checks (Q4, ACHS, Q1)
- What kind of IV access?
- What kind of drips?
- Lab values/orders
- Plan of care
4. Patient involvement in shift report
There is a lot of evidence that when a patient is involved in their care they experience improvements in safety and quality. This also creates a time for patients to host their questions and concerns.
Tips on Writing Your End of Shift Nurse Note
- Be objective
- Write your note based on what you see, hear and do. Not what you think.
- However, your opinion can be verbalized to other healthcare professionals so they can get a better picture of the patient
- Read the veteran nurses notes
- Older nurses balance facts with insight.
- Find a mentor
- Ask an experienced nurse to give you constructive feedback.
- There are charge nurses or nurse educators you can utilize.
- Describe specific events/observation
- Color pink, swelling to lower extremities, pain 4/10.
- Details instead of conversations
- There is no need to include dialogues of what you’ve had about patients between providers
- Notes responses from treatments
- Expressing how the patient responded to dialysis, Hemodialysis took out 2L. Patients tolerated well, Vital signs stable (VSS).