The patients admitted into the hospitals will have to be taken care of by the duty nurses, mostly certified nursing assistants, or CNAs, for general care and follow up of the treatment as per the instruction of the attending doctor or the registered nurse.
Normally, each CNA will have a fixed working time and he or she will be relieved from the duties from the other nurse taking over the shift duties. The nurses will be changing after the shift period ends, but the patients might be there in the hospital ward for treatment for a longer period of time, may be a couple of days or more depending upon the intensity of their ailment.
In order to ensure that the patient is given adequate care, it is the responsibility of the nurse getting relieved from day’s work to pass on the information and developments of the patient to the nurse taking over the duties. The nurse should record the details in a report, called as the “change-of-shift” report.
The important things that should be included in the “change-of-shift” report are as follows:
1. The report should include the name of the patient, the room number, or bed number, nature of the problem being treated and diagnosed, and the doctor attending on that patient.
2. Details of any abnormalities noticed in the past 8-10 hours for the patient
3. Details of the diagnostic procedures carried out and the status of the results
4. If the nurse had witnessed any variations from the normal routine duties, things other than normal, then the same should also be recorded in the report.
5. Details of activities that are yet to be completed should also be recorded in the report. For example, it might take a couple of hours, if not more, to get the X-ray report from the laboratory. If the X-ray process has been completed but the report is not yet received, then it must be recorded in the report, so that the incoming nurse will follow up the report.
6. The report should also include the status of the invasive treatment, such as when was it administered and how long does it take to get completed, the rate of flow, and other details.
7. If there are any changes in the plan of action advised by the doctor, then the same should also be mentioned in the change-of-shift report for the new nurse to follow up.
Each CNA should ensure that the report is written clearly and legibly so that the care of the patient is not compromised for lack of communication between the nurses changing over between shifts.