focuses on different forms of reporting

1. REPORTING
By:
Mr. M. Shivananda Reddy

2. Report
• A report is oral, written, or computer-based
communication intended to convey information
to others.
• The purpose of reporting is to communicate
specific information to a person or group of
people.
• A report, whether oral or written, should be
concise, including pertinent information but no
extraneous detail

3. Types of reports:
Reports commonly used by nurses include
• Hand off report
A.Change of shift report
B. Transfer report
• Telephone reports
• Incident reports

4. Hand off reports
• Hand-off reports happen any time one health
care provider transfers care of a patient to
another health care provider.
• The hand off report may be change of shift
report or transfer report

5. • The purpose of hand-off reports is to provide
better continuity and individualized care for
patients.
• For example, if you find that a patient
breathes better in a certain position, you relay
that information to the next nurse caring for
the patient

6. Change-of-shift report
Change-of-shift report is given to all nurses on the
next shift
• It includes up-to date information about a
patient’s condition, required care, treatments,
medications, and any recent or anticipated
changes.

7. Transfer report
Transfer report is given whenever the patient is
transferred to other health care unit.
It can happen between:
• Nursing unit-to-nursing unit transfer
• Nursing unit to diagnostic area.
• Special settings (operating room, emergency
department).
• Discharge and inter-facility transfer

8. • Hand off report can be given face-to-face, in
writing, or verbally such as over the telephone
or via audio recording

9. • A sample hand off report format as follows:
• Background information (name, age, and medical
diagnosis);
• Primary health problem;
• Unusual occurrences;
• Discharge planning issues;
• Identification of significant changes in measurable terms
(e.g., Pain scale);
• STAT, or prn medications
• Care required such as medications that need to be started,
• When a dressing needs to be changed next;
• Progress with interventions; and family involvement.

10. Telephone Reports
• Health professionals frequently report about a
client by telephone.
• A registered nurse makes a telephone report
when significant events or changes in a patient’s
condition have occurred.
• Nurses inform primary care providers about a
change in a client’s condition; a radiologist
reports the results of an x-ray study

11. • The nurse receiving a telephone report should
document the date and time, the name of the
person giving the information, and the subject of
the information received, and sign the notation.
• For example 16/6/15 10.35 am Mr. Sahoo,
laboratory technician, reported by telephone that
Mrs. Anjali’s hemoglobin is 6 gm/dl. Sign at the
end

12. • The person receiving the information should repeat it
back to the sender to ensure accuracy.
• It is important that the nurse be concise and accurate.
• Telephone reports usually include the client’s name and
medical diagnosis, changes in nursing assessment, vital
signs , significant laboratory data, and related nursing
interventions.
• The nurse should have the client’s chart ready to give
the primary care provider any further Information
• After reporting, the nurse should document the date,
time, and content of the call

13. Telephone Orders & Verbal Orders:
• A Telephone Order (TO) occurs when a health
care provider gives an order over the phone to a
registered nurse.
• A Verbal Order (VO) involves the health care
provider giving orders to a nurse while they are
standing near each other.
• TOs and VOs usually occur at night or during
emergencies and frequently cause medical
errors

14. • ThE NURSE reads the order back to the health
care provider, called read back, and receives
confirmation from the person who gave the
order that it is correct
• The health care provider later verifies the TO or
VO legally by signing it within a set time (e.g.,
24 hours) as set by hospital policy.

15. Guidelines for telephone and verbal
orders:
• Clearly determine the patient’s name, room number, and
diagnosis.
• Repeat any prescribed orders back to the physician or
health care provider.
• Use clarification questions to avoid misunderstandings.
• Write TO (telephone order) or VO (verbal order), including
date and time, name of patient, the complete order; And
sign at the end.
• Follow agency policies; some institutions require
telephone orders to be reviewed and signed by two
nurses.
• The health care provider must co-sign the order within
the time frame required by the institution (usually 24
hours).

16. Incident or Occurrence Reports
• An incident or occurrence is any event that is not
consistent with the routine operation of a health care
unit or routine care of a patient.
• Examples of incidents include
• Patient falls,
• Needlestick injuries,
• A visitor having symptoms of illness,
• Medication administration errors,
• Accidental omission of ordered therapies, and
• Circumstances that lead to injury or a risk for patient
injury.

17. Incident Report
• Incident (or occurrence) reports are an important
part of the quality improvement program of a unit.
• Always contact the patient’s health care provider
whenever an incident happens
• In the incident report form document an objective
description of what happened, what you observed,
and the follow-up actions taken.