ward report

WARD REPORT FOR NURSES.

This is the record/information about the patient and ward that the nurse pass to fellow nurses verbally and written form stating what was done and what should be done to a patient and in the ward.

It contained a record of ward events, ward equipment, staffs, changes made or upcoming changes, drugs this include stock out, patient, ward supplies.

The main purpose of reporting is for passing out information for continuous nursing care, nurse and patent’s safety.

When do nurses report

·       At the beginning of the ward shift

·       At the end of the ward shift

·       Any incident occurrences or accidents

·       Any procedure done

·       At the end of the month, every 3 months it is called quarterly report, every 6months and yearly this also call annual report(for in charges)

·       Staff behaviour .that is to say conflict, shifting ,abscentism, good and bad performance.

·       When new Ward equipment is brought

·       When there is training, they report before, during and after training.

Types of ward report

There are two main types ;

·       Verbal/oral report. This is the report given by word. The nurse says the report to another nurse verbally.

·       Written report. This is the report written down in a book, system, sheet of papers.

All other report follows the above types. other types include;

·       Shift report. this is the report given at the end of the duty.

It is given by the nurses who as finish the duty to the new nurses who are reporting to take over for the next shift.it is given both in written and verbale.

·       Ward round report/doctors round report. This is a report given after doctors has conducted ward round.

It is given by both the doctors and the round nurse. doctors hand over to the fellow doctors about the patients and nurses report to nurses.

the information reported after ward round are; very ill patients, investigations, treatment add or remove, nurses care plan and integration with other department.

·       Activity report or operational report. this are report given on a daily routine in the ward for example health talk, ward cleanliness, bed making ,linen collection, equipment status.

·       Quality assurance report. This is a report given at the end of a set target of objective, it more like evaluation report.

·       Clinical report. report given about the patient condition eg how the patient is being managed, the sates of the patient, the medication, the plan.

Order of giving ward report/handing over report

·       On changing shift or duties, a verbale report should be given then followed by written report.

·       Hand over the number of patient.

·       Hand over the medications.

·       Hand over equipment and supplies including their condition.

Point to note

Report is written by the nurse in charge of the shift.

Always write the time date, the month, the year on top of the page.

Write the name shift and the ward on top of the report.

Alway be precise, straight forward and systematic in your writing.

Signs at the end of the report including all the nurses on duty

Use pen not pencil

Composition of the ward report/points to be reported/components

Patient

·       Total number of patient in the ward

·       Severly ill patients.

·       Pre operative patients.

·       Post operative patients.

·       Patient on a special treatment

·       Patient for close observation

·       Patient transferred

·       Patient discharged

·       Death

Equipment and supplies

·       Emergency medications and their state

·       Emergency equipment

·       Special Medications needed

·       Stock out

·       Broken equipment and equipment out of use

Staff

·       Staff off duty

·       Number of staff allocated in the ward

·       Staff on duty

·       Staff on call

·       Staff on leave

·       Staff available on ground

·       Staff for particular shift

Services.

·       Available laboratory services

·       Available imaging services

·       Other services they introduce

·       Services they no longer providing

Important of giving report/handing over ward report/important of giving report/benefits of reporting/why do nurses give report.

·       communication. informing the fellow staff about what  was done ,what do be done and patients current conditions.

·       Continuity of nursing care. continue with a ongoing patient care.

·       Adoptability. when there are services no longer be offer but critical in the care the nurse as to use available resources and adapt to the situation.

·       Build strong relationship and team work when reported early staff can cooperated.

·       Guide for making evidenced base decision making.

·       Help in identifying problems and the solution for the problem

·       Patient and nurse safety. reporting about patient help protect the health worker and patient speciality in contagious diseases like Ebola, cholera.

·       Reporting help in planning. planning is done based on the information reported.

·       Help in minimising the reassure wastes and enhance efficiency.

·       Provide topic for research leading to better understanding and solution.

·       Evaluation of the department performance.

·       Cost effective of services patient know available services and don’t west time and money.

·       Effective patient care. when reported about the patient doctor will look for the best alternative for the patient.

·       Help nursing in knowing their patient better as in their care.

Procedure of giving ward report

1.     Prepare. a nurse has to gurther all the needed information before writing or giving report example patient chart, registers and duty roster, count the equipment and supplies

2.     Summarised all the data including the very sick patient, number of patient, items.

3.     Report about the patient, staff, equipment and supplies and services.

4.     Report about the shift situation the challenges and shortages

5.     Summarised the report

6.     Sign

7.     Hanover the report

8.     Do bed to bed handover ie physical handover.

What are the factors to consider for effective reporting/measures for effective ward report.

·       Finish all the started work/procedure before reporting.

·       Prepper well before reporting by gathering all the necessary information.

·       Reduced unnecessary destruction. from fellow nurses or patient dedicate other work to the colleague on duty.

·       Write clearly for easy reading

·       Active listen

·       The report should be precise easy to understand.

·       Communicate effective

·       Use a standard reporting tools

Challenges in writing reporting.

Time limited

Complex work

Work overload.

Little data not enough to make a report.

Incomplete register

Pressure from the manager.

Poor communication

Poor listening skills.

Laziness to read the written report

2. Frequently Asked Questions (FAQs)

(Generated from commonly asked ward-report questions, but answers are based only on your text)

Q1. What is a ward report?

A ward report is the process where an outgoing nurse communicates patient and ward information to the incoming nurse during shift change.

Q2. Who gives a ward report?

The ward report is given by the outgoing nurse to the incoming nurse.

Q3. When is a ward report given?

A ward report is given during a shift change.

Q4. What should be done before giving a ward report?

The nurse should prepare by reviewing patient records, charts, and ward notes.

Q5. What information is given at the start of a ward report?

The ward name, date, time, shift, and total number of patients are stated.

Q6. What patient information is included in a ward report?

Information includes admissions, discharges, transfers, deaths, diagnosis, patient progress, treatments, investigations, and pending procedures.

Q7. Why are critically ill patients mentioned in a ward report?

They are highlighted so the incoming staff can give them special attention and care.

Q8. Are incidents reported during ward report?

Yes, any incidents, emergencies, or unusual events during the shift are reported.

Q9. Is equipment and staffing discussed in a ward report?

Yes, availability of equipment, supplies, and staffing challenges is mentioned.

Q10. What happens at the end of a ward report?

Questions are allowed, responsibility is formally handed over, and the report is documented while maintaining confidentiality.

References

Nursing procedure manual

More report formatting  https://sonams.ac.ug/Notes/WARD%20REPORT%20ND_054057.pdf