Nurse Handoff Reports: Best Practices and Essential Tips for Success

Nurse handoff report, also known as shift report, is a crucial communication process that takes place between nurses at the end of a shift or when a patient is transferred to another unit or facility. The primary goal of a handoff report is to ensure continuity of care and patient safety by sharing vital patient information and providing updates on their condition and treatment plan. In this blog post, we’ll discuss what should be included in a nurse handoff report to ensure effective communication and promote patient-centered care.

Patient Information

The first and foremost thing that should be included in a nurse handoff report is basic patient information. This includes the patient’s name, birth date, age, and sex. The nurse should also mention the patient’s primary diagnosis, any comorbidities, and the reason for admission or transfer to another unit. Providing this information helps the receiving nurse to identify the patient and understand their medical history.

Medical History

The patient’s medical history is an essential aspect of the nurse handoff report. The nurse should share any significant past medical history, including allergies, surgeries, medical conditions, and any relevant family history. This information is crucial for the receiving nurse to identify potential risk factors, anticipate the patient’s needs, and ensure that the patient receives appropriate care.

Current Medications

You do not need to discuss the patient’s entire medication regimen as that would make the shift report too lengthy. Instead, focus on main points such as if the patient was started on any new medications and if there were any dosage adjustments. This information helps the receiving nurse to avoid any potential medication errors, including missed doses, duplicate therapy, and drug interactions. If the patient has any medication allergies, this information should also be shared to ensure that the patient receives safe and appropriate care.

Treatment Plan

The nurse should provide an overview of the patient’s treatment plan, including any upcoming tests, procedures, or interventions. The nurse should also share the results of any recent tests or diagnostic procedures, such as blood tests, imaging studies, or electrocardiograms (ECGs). This information helps the receiving nurse to anticipate the patient’s needs and ensure that they receive timely and appropriate care.

Vital Signs

The nurse should share the patient’s vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation. The nurse should also share any recent changes in the patient’s vital signs and the interventions that were implemented to address these changes. This information helps the receiving nurse to identify any potential changes in the patient’s condition and respond appropriately.

Wound Care

If the patient has any wounds, it is essential to provide detailed information about the wound care plan during handoff report. This information should include the location of the wound, the type of wound, the size of the wound, the stage of healing, and any interventions or treatments that have been initiated. The nurse should also share any important wound assessment findings, such as the presence of drainage or signs of infection.

It is also important to share information about any wound care products or supplies that have been used, such as dressings or topical agents. The nurse should provide information about the frequency and method of wound dressing changes, and any specific instructions or precautions that must be taken.

By sharing comprehensive wound care information during handoff report, the receiving nurse can ensure that the patient’s wounds are properly monitored and treated, and that they are on track for optimal healing.

Pending Tasks

The nurse should share any pending tasks, including medication administration, laboratory tests, or diagnostic procedures, that need to be completed. The nurse should also provide an update on any follow-up consultations. This information helps the receiving nurse to ensure that the patient receives timely and appropriate care.

Critical Incidents

The nurse should share any critical incidents, including falls, medication errors, or changes in the patient’s condition that require immediate attention. The nurse should also share any adverse events that occurred during the patient’s hospitalization, such as infections, pressure ulcers, or adverse drug reactions. This information helps the receiving nurse to identify potential risks and respond appropriately.

Family Concerns

The nurse should share any concerns or requests expressed by the patient or their family during their hospitalization. The nurse should also provide an update on any communication that occurred between the patient and their healthcare team, including any changes in the patient’s preferences or goals of care. This information helps the receiving nurse to ensure that the patient receives patient-centered care and that their needs and preferences are considered.

Additional Information

The nurse should also share any additional information that may be relevant to the patient’s care, such as their level of consciousness. Are they alert and oriented? If so, by how much? Are they incontinent? Do they ambulate? Can they feed themselves? The nurse should also share any concerns or challenges that they faced during their shift that may impact the patient’s care. This information helps the receiving nurse to anticipate potential challenges and ensure that the patient receives holistic and individualized care.