How to Give a Solid Nursing Report

• Share Story
• 
• 
• 

Are well-developed nursing reports a dying art form? With ongoing staffing shortages and increasing patient loads, overworked nurses may be too exhausted to think clearly at the end of a shift. It can be easy to dismiss reporting as one more mundane task and rush through patient information for the sake of clocking out on time.

However, during nursing handoff, it’s crucial to provide a broad overview of the patient’s condition, including the events that led to their hospitalization and their path to recovery. An effective nursing report is clear, concise and comprehensive to ensure it’s helpful to the next nurse. Explore what makes a nursing report successful and discover essential tips for clear and effective communication from Vivian Health.

Essential Components of a Nursing Report

When communication gaps occur during nursing handoff, patients risk potential harm. Miscommunication may lead to medication errors, missed treatments or care delays, all of which can significantly affect patient outcomes.

Just as nurses begin preparing patients for discharge from the moment they’re admitted, you can start getting ready for your end-of-shift nursing report from the very beginning of your shift. To do this, gather a thorough patient history during the initial handover.

Remember, receiving an incomplete report from the previous shift doesn’t excuse providing an inadequate report yourself or lacking essential details about your patient. It’s your professional responsibility to fully understand your patient’s condition. If the outgoing nurse hasn’t given you the necessary information during the handover, take the initiative to review the patient’s electronic health records (EHR) and chart to ensure you have a complete picture.

The most important details to include in your nursing report are:

• Patient Identification and Status: Include the patient’s name, age, room number and critical medical identifiers. Be sure to mention status details such as attending doctor, code status or any isolation precautions.
• Summary of Medical History and Current Diagnosis: Provide a concise overview of the patient’s relevant medical history, current diagnosis, the care plan in place and the primary goals of care.
• Updates on Treatments and Medications: Document and report any treatments administered during your shift, including details of medications, doses and any adjustments made to the regimen.
• Changes in Medical Condition: Document any changes in the patient’s condition, including changes in vital signs, new or worsening symptoms or abnormal lab results.
• Pending Tests or Procedures: Mention any upcoming tests, procedures or consultations the next shift needs to complete.
• Patient Preferences and Needs: To ensure personalized care, include patient-specific details like dietary restrictions, mobility needs or communication preferences.
• Safety Concerns: Highlight any safety issues, such as infection control measures, fall risks or behavior concerns, that may require extra attention.
• Recommendations for Follow-up: Recommend ongoing care, monitoring or interventions to ensure a smooth transition between shifts and continuity of care.

The better you know your patient from the beginning of the shift, the better you can care and advocate for your patient and their health. When the end of your shift comes, you’ll be prepared to effectively explain to the oncoming nurse why you provided specific treatments and interventions.

Using Effective Communication Techniques

It’s easy to get sidetracked during a change of shift nursing report, but staying concise is critical. A long, drawn-out report can lose the listener’s focus and cause you to miss important details. Stick to the facts that matter. For example, if a patient is confused, you can describe them as pleasantly or aggressively confused and offer a brief example. However, avoid going down a 5-minute rabbit hole of personal reflections or unnecessary details. Keep it clear and to the point.

Use clear language, summarize key points and encourage questions to ensure comprehension from the receiver. It is also helpful to pause regularly to check for understanding and confirm that the listener can follow along.

SBAR: The Standard Nursing Report Tool

When you give your nursing report, following a systematic approach is the best way to stay confident and keep yourself on track. Start your report using the SBAR format (Situation, Background, Assessment, Recommendation) and transition into a head-to-toe review of symptoms within the assessment section.

Situation: Start with a concise one-liner describing the patient and the reason for their hospitalization. This brief summary should include essential details such as the patient’s weight, code status and any isolation precautions. The goal here is to quickly orient the oncoming nurse to the patient’s primary concern and immediate care considerations.

Background: Next, provide relevant background on the patient’s health history, including any past hospitalizations or surgeries that may relate to their current illness. Focus on details that could impact the patient’s care or recovery during this admission, giving the receiving nurse insight into underlying health factors.

Assessment: In the Assessment section, follow a head-to-toe review of the patient’s symptoms and condition. Start with the neurological system and progress through the cardiac, respiratory, gastrointestinal, genitourinary, integumentary and psychosocial systems. After the systems review, cover details about the patient’s IV access, noting which fluids or medications are infusing through each line. This comprehensive overview helps ensure the oncoming nurse clearly understands the patient’s current status.

Recommendation: Conclude with Recommendations for the upcoming shift. Outline any labs the oncoming nurse needs to collect, procedures scheduled for the patient and any anticipated care needs. This section should provide the oncoming nurse with a roadmap of what to expect and prepare them for specific tasks or challenges that may arise during the shift.

A nursing report doesn’t need to take you all day, but a systematic approach is essential for an efficient and effective handoff. 

4 Common Nursing Report Challenges and Solutions

One of the biggest challenges nurses face during handoff is the pressure of time constraints. When you’re racing to wrap up your shift, it’s easy to feel overwhelmed when giving a thorough report. Here are four ways you can address this challenge:

1. Prepare for the Unexpected

Start preparing for the end-of-shift routine at least two hours early. This preparation includes tasks like emptying catheters, taking vital signs, reviewing lab results, changing IV lines, administering medications and completing as many necessary procedures as possible in advance. 

By staying ahead on routine tasks, you’ll have the flexibility to handle any last-minute issues that arise, such as calling a doctor for new orders or managing a sudden change in a patient’s condition. You’ll also be able to provide emotional support to patients and families without feeling rushed. Avoid rushing in nursing care; the unpredictability of patient needs means each moment counts.

2. Address Lack of Shift Overlap

One common challenge is the limited or nonexistent overlap between shifts. With increasing demands, facilities often expect nurses to arrive early or stay late to ensure smooth transitions. Effective handoff requires at least 15 minutes of overlap to provide a comprehensive report for all patients at the end of a shift. 

In many facilities, however, it has become standard for nurses to arrive 15-30 minutes early to help colleagues leave on time, though this is often done without pay. Ideally, schedules should include an overlap period—for example, having the outgoing shift end at 7:15 and the incoming shift begin at 7:00. This setup not only supports a thorough report but also ensures patient safety and continuity of care. In my experience across different facilities, only one hospital consistently allocated this overlap time, significantly improving the handoff quality.

3. Prioritize Complex and Emergency Cases

Communicating very complex cases or emergency situations introduces an additional challenge during handoffs. In these cases, it’s essential to get straight to the point, focusing on the most relevant information. Prioritize the patient’s pertinent medical history, current condition, treatment plan and any immediate needs. Keeping your report organized and concise helps ensure that no critical information slips through in high-pressure situations.

4. Ensure Accuracy and Privacy

Accuracy and patient privacy are fundamental to effective verbal and written reports. Use clear, precise language and double-check your information before passing it on to the incoming nurse. Protect patient confidentiality by avoiding discussions of sensitive details in public areas or with individuals who don’t need to know. Although balancing these priorities can be challenging, they are essential to maintaining trust and delivering high-quality patient care.

Using Technology in Nursing Reports

EHR has transformed how we handle nursing reports. With all that patient information just a click away, gathering essential details like medical history, medications and allergies has never been easier. This access helps us communicate more effectively during nursing reports and ensures we don’t miss any critical information. Plus, with personalized healthcare tools like secure messaging apps and voice recording systems coming into play, we’re improving how we share information with our teams.

How Technology Can Streamline the Reporting Process

Healthcare technology is a game changer when it comes to streamlining the nursing reporting process. By reducing the time spent on manual documentation, we can focus more on providing care. For example, EHR systems allow us to quickly input and retrieve patient data, making it easier to prepare concise and informative handovers for the next shift. 

I experienced the use of technology firsthand as a float nurse in the ICU during my last travel contract. We used taped recordings for handovers, and while I initially thought it felt a bit old-fashioned, I quickly saw its benefits. Each nurse would leave behind detailed recordings filled with all the essential info. I loved reviewing these tapes at my own pace, without any interruptions. Traditional handovers can feel chaotic—how often do we get interrupted and lose track of important details? 

With taped recordings, I could anticipate what I needed to cover, making the whole process feel much more organized and efficient. This process also allowed the previous shift to leave on time without staying for the report. If there were any gaps in reporting, the previous nurse would usually leave their phone number and encourage a quick call if there were questions.

The Importance of Effective Nursing Reports

Delivering and receiving thorough nursing reports is essential for providing top-quality patient care. When receiving a report, ask questions and clarify anything that’s unclear from the previous shift. If the departing nurse doesn’t have the answers, find them through the EHR or ask the patient. Make sure you understand the overall picture—why your patient was admitted and what to expect throughout the day—so you can provide appropriate care and be prepared to pass on that critical information to the next shift. Clear, concise reports using a systemic approach like the SBAR streamline nursing work and ensure patients receive the best care possible. 

Ready to enhance your nursing career with a new staff role or travel contract? Browse jobs on Vivian Health to find opportunities that prioritize efficient communication and support your nursing career.

Browse Jobs

Editor’s Note: This blog post was originally published in December 2021 and was updated in December 2024 to reflect current nurse reporting practices.