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ICCU - Bedside Shift Report Using SBAR(T) Format Situation

S

Background

Assessment

Recommendation

Thank You

Offgoing RN Manage Up - "I'm going home now. Nurse xyz will be your nurse now for the next shift. I have worked with nurse xyc for # years & I can tell you I'm leaving you in good hands.” (or some other managing up phrase, e.g. “nurse xyz is one of our most experienced nurses ; nurse xyz is going to take care great care of you,” etc.) Oncoming RN Introduce self. Update white board. Check armband / (allergy band) while asking patient to state his/her name & date of birth. Offgoing RN Involve patient in change of shift report - "I'm about to give report to nurse xyz. Please listen so at the end you can ask any questions or fill in any additional information that nurse xyz will need to know to care for you during this shift." Give a brief & pertinent past medical history; explain any co-morbidities or events that led up to this hospitalization or that are having an effect on the patient's condition at this moment in time.

B

Admitted for ...... Pertinent History ...... Pertinent Labs / test / procedure ....... Current therapy (meds, tx, monitoring, dressings, drains, tubes,O2) IV sites/lines (PICC, CVC lines, ports) Current Vital Signs ..... Pain (rating, drug, last dose, follow up assessment, include patient in discussion) Special needs (precautions, isolations, fall risk, fluid restrictions) Consults (physician, social worker, wound care, dialysis) Teaching Needs (diabetic, wound care) ASK the patient ! Discharge Plan and Needs ASK the patient ! Oncoming RN Ask patient if they have any questions.

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T

Offgoing RN Inform the oncoming nurse of what you have assessed (Review Of Systems) and or noted during your shift. Include any information or tasks that you have completed. Mention what the oncoming nurse will need to complete or follow up on. Be specific about what is going on with the patient now. Oncoming RN Review Chart / check documentation. Conduct a quick physical assessment and check all IV sites and pumps for accuracy. Assess patient’s pain using a pain scale. Offgoing RN Review all orders and plan of care with oncoming RN (test, tx, meds, IV sites, drips) Include relevant meds that have been ordered and any ancillary or support services that are working with the patient such as respiratory, radiology, social worker, etc.) Ask the patient “Do you have any questions? Is there anything else the RN needs to know at this time?” Oncoming RN Validate orders / plan of care Ask any questions to offgoing nurse Thank the Patient Offgoing RN and Oncoming RN Prior to leaving the room as the patient the following: Is your PAIN under control? Are you Comfortable (POSITION)? Do you need to go to the bathroom? Do you UNDERSTAND the plan of care? Do you know what you are waiting for and what will happen next? Do you have any CONCERNS we can address? Use Closing Key Words Offgoing RN Nurse xyz will take very good care of you. Thank you for allowing me to take care of you today. Oncoming RN Is there anything you need right now? I will be back to check on you in about an hour.


Version 3.0 - 4/21/11 insď Š

CCU Bedside Shift Report Template  
CCU Bedside Shift Report Template  

Guidelines for end of shift report.

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