Page 201 - Saunders Comprehensive Review For NCLEX-RN

B. Reports

1. Reports should be factual, accurate, current, complete,
and organized.
2. Reports should include essential background
information, subjective data, objective data, any
changes in the client’s status, client problems or
nursing diagnoses as appropriate, treatments and
procedures, medication administration, client
teaching, discharge planning, family information, the
client’s response to treatments and procedures, and
the client’s priority needs.
3. Change-of-shift (handoff) report
a. The report facilitates continuity of care
among nurses who are responsible for
a client.
b. The report may be written, oral,
audiotaped, or provided during
walking rounds at the client’s bedside.
c. The report describes the client’s health
status and informs the nurse who
assumes care about the client’s needs
and priorities for care.
d. The report may be done at the client’s
bedside to allow the client to
participate in care planning, as well as
to establish the stability of the client
before the oncoming nurse assumes
care.
4. Telephone reports
a. Purposes include informing a PHCP of
a client’s change in status,
communicating information about a
client’s transfer to or from another unit
or facility, and obtaining results of
laboratory or diagnostic tests.
b. The telephone report should be
documented and should include when
the call was made, who made the call,
who was called, to whom information
was given, what information was
given, and what information was
received.
5. Transfer reports
a. Transferring nurse reports provide
continuity of care and may be given by
telephone or in person (Box 7-6).
b. Receiving nurse should repeat transfer

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