FREE 10+ Nursing Report Samples [ Accident, Patient, Hospital ]

A nursing report is a written or verbal documentation of a patient’s health status, nursing care plan, and any changes or updates that have occurred during a nursing shift. The report is typically given by the outgoing nurse to the incoming nurse to ensure continuity of care for the patient. The nursing report includes details about the patient’s medical history, current medication lists, vital signs, and any treatments or interventions that have been administered. It may also include notes on the patient’s mental or emotional state, as well as any concerns or questions the nurse has about the patient’s care plan. Nursing reports are an essential part of healthcare communication and are used to ensure that patients receive the highest quality of care possible.

How To Make Nursing Report?

Another benefit of nursing reports is that they provide a platform for communication between healthcare providers. When a nurse completes a nursing report, they may include any questions, concerns, or recommendations they have for the patient’s care plan. This information can be shared with other healthcare providers, such as doctors, specialists, or physical therapists, enabling them to make informed decisions about the patient’s care. A nursing report is a written or verbal documentation of a patient’s health status, care plan, and any changes or updates that have occurred during a nursing shift. The following are steps on how to make a nursing report:

Step 1- Gather Information

Before starting to make a nursing report, gather all relevant information about the patient, including their medical history, current medications, vital signs, and any treatments or interventions that have been administered during the shift. To ensure that the nursing report is clear and concise, use a standardized format that includes all relevant information about the patient’s condition.

Step 2- Start with Patient’s Identification

The nursing report should begin with the patient’s name, age, sex, and medical record number.  Include any chronic conditions, previous illnesses, allergies, or surgeries the patient has undergone.

Step 3- Document Current Status

Record vital signs such as blood pressure log, heart rate, respiratory rate, temperature log, and any new symptoms or changes in the patient’s condition. Include all medications administered, including the type, dose, and frequency, and any treatments or interventions provided during the shift.

Step 4- Include Notes

Record any observations about the patient’s mental or emotional state, including their mood, behavior, and any concerns or questions the nurse has about the patient’s care plan.  Include any recommendations or questions you have about the patient’s care plan to ensure that other healthcare providers have a clear understanding of the patient’s condition.