Introduction:

In the dynamic landscape of healthcare, the art of nursing report example is a skill that transcends mere documentation; it is a crucial mechanism for effective communication and the provision of high-quality patient care. In this article, we will explore a practical example of nursing reports, illuminating how these documents become instrumental in conveying essential information, fostering collaboration, and ensuring the well-being of patients.

Example of Nursing Reports:

Patient Information:
- Name: Mr. John Anderson
- Age: 68
- Gender: Male
- Medical History: Hypertension, Coronary Artery Disease

Shift Change Report (End of Morning Shift):
- Handoff from Outgoing Nurse:
- Mr. Anderson admitted for chest pain; diagnosed with acute coronary syndrome.
- Stable overnight; no significant changes in vital signs.
- Administered nitroglycerin as ordered, pain relieved.
- Anticipate stress test later today.

- Current Status:
- Vital Signs: Stable; blood pressure 130/80 mmHg, heart rate 78 bpm.
- Oxygen Saturation: 98% on room air.
- Pain: Rated 2/10 on pain scale; no acute distress.

- Medications Given:
- Morning medications administered: Aspirin, Metoprolol, Atorvastatin.
- Nitroglycerin PRN for chest pain; last dose given 0600.

- Interventions and Assessments:
- Assisted with morning hygiene and provided education on cardiac precautions.
- ECG monitoring every 4 hours; no arrhythmias detected.
- Ambulated in the hallway with no complaints of pain or discomfort.

- Collaboration with Healthcare Team:
- Consulted with Cardiologist for stress test scheduling.
- Communicated with Physical Therapy for mobility assessment and exercise plan.
- Discussed plan of care with the nursing team for consistent approach.

- Patient and Family Education:
- Educated Mr. Anderson on medication regimen and importance of cardiac rehabilitation.
- Reviewed signs and symptoms to report, emphasizing the significance of immediate notification.

- Shift Goals and Plan:
- Monitor for any changes in pain, vital signs, or ECG.
- Coordinate with Cardiology team for stress test results.
- Encourage and support patient participation in cardiac rehab.

Conclusion:

This example of why reporting is important for nurses illustrates the comprehensive nature of these documents in the provision of patient care. From essential patient information to interventions, collaborations, and educational efforts, the nursing report serves as a comprehensive guide for the healthcare team. By sharing critical details, nurses contribute to the continuity of care, ensuring that the next shift is well-informed and ready to build upon the progress achieved. This transparent and systematic approach to nursing report writing exemplifies the dedication of healthcare professionals to delivering patient-centered care of the highest quality.