Giving a good bedside handoff report is not something that comes naturally, it’s something nurses learn through lots of practice. Here are the essentials of a good bedside handoff report to keep you ahead of the game!
Introduction
Introduce the oncoming nurse to your patient. If your patient is sleeping, you can skip this step but still go into the patients’ room to do your bedside handoff report. This way if the oncoming nurse has any questions, your patient is right in front of you. Plus, you can verify with the oncoming nurse the fluid and any medications that are running and at what rate.
“Suzy this is Carol, she is going to nurse for the day. I’m just going to give her a quick run down on why you’re here.”
For more on IV fluids, check out Nursing Fundamentals: A Guide to Intravenous Fluids.
Patient Information
Giving the oncoming nurse the patients’ information is the easiest part of your bedside handoff report. State the patients name, their age, any allergies they may have, their code status, and how long they have been admitted for. Along with if the patient is alert and/or oriented and their mobility status. This can all be found in the patients’ chart and should sound something like this,
“This is Suzy Smith, she is a 57 y/o (year old) female. NKA (No known allergies). Full code. She came in on October 4th. She is A&O x4 (fully alert and oriented) and ambulates independently.”
Visit Charting Tips for New Nurses for charting navigation help.
Situation
Now it’s time to give the oncoming nurse a reason as to why the patient is here. This should include 1) her initial chief complaint, meaning what brought her to the hospital, 2) her admitting diagnosis, what was she admitted for, and 3) any history of the present illness, if applicable. For example,
“She came with c/o (complaints of) severe abd (abdominal) pain and tenderness. She was diagnosed with appendicitis. Pt (patient) does have a hx (history) of abd pain on and off for about 3 months.”
For more information on how to treat a patient in pain, visit Nursing Fundamentals: A Guide to Pain and Patient Education: How to Effectively Manage Acute and Chronic Pain.
Background
Does this patient have any other comorbidities? Has she had any previous abdominal surgeries related to why she’s here now? What is her pertinent past medical history?
“Suzy has a history of DM (diabetes) type 2. She does blood sugar checks at home and has received insulin on my shift.”
Be sure to visit Nursing Fundamentals: A Guide to Diabetes for more information on diabetes.
Labs/Imaging/Procedures
Were any labs or imaging taken in the emergency department? What were the results? Are there any labs pending? Has she received surgery since being hospitalized?
“Patient did receive an US (ultrasound) on admission which came back positive for appendicitis. No other labs have been drawn and there aren’t any further lab orders at this point.”
Visit Medical Abbreviations You Must Know for more.
Assessment
Now you’re going to want to give the oncoming nurse the most recent assessment abnormalities. Is she in pain? Does she have any open wounds? Does she have any PRN pain medications on board? Are they helping? Does she have an IV? What’s running in her IV? For example,
“Pt (patient) is still c/o (complaining of) abd (abdominal) pain, worse with movement. Along with intermittent nausea. Pt denies emesis. There is PRN (as needed) Norco ordered that does seem to help with her pain. She was last given Norco at 1600 so she is not due again until 2000 which she is aware of. She is also on IV ABX (antibiotics), Zosyn which is currently running at 100 mL/hr. No additional fluids have been ordered.”
Also see How to do a Quick yet Effective Head-to-Toe Assessment for assessment tips as well as Nursing Fundamentals: A Guide to IV Therapy and A Guide to Intravenous Fluids for more IV info.
Plan/Recommendations
This section should address why the patient is still here and what criteria needs to be met before she is able to return home. What are the plans the doctor has put in and are there any nursing recommendations that would help the oncoming nurse during their shift? For example,
“She is currently receiving IV ABX (antibiotics) and is scheduled for a possible appendectomy tomorrow at 1400, pending doctors’ morning assessment. She is NPO (nothing by mouth) just in case and has been since 1200. The plan is to continue her ABX and NPO status until the doctor decides if the appendectomy is best. Her pain medication is to be continued PRN. We did discover that heat packs are helping with her abd (abdominal) pain, so she knows to call you when she needs a new one.”
Treatment Team
If there is someone the oncoming nurse needs to follow up with or a specific doctor assigned to the case, then you can add who is on the treatment team in your bedside handoff. In this case, mentioning the surgeon who will round in the morning to determine if an appendectomy is necessary would be good to add.
“Doctor Shaw is her surgeon and will be rounding in the morning.”
Questions
At this point you can ask the patient if you missed anything as well as ask the oncoming nurse if he/she has any questions. You might have accidentally forgot something so giving the patient and the oncoming nurse a chance to add anything is helpful when giving your bedside handoff report.
“Did I miss anything? Do you have any questions for me?”
And you’re done!
Remember practice makes perfect and everyone is going to give their bedside handoff report a bit differently. Break it down, answer any questions, and give yourself a pat on the back!
Also visit these helpful posts for new grad nurses:
- 10 Best Amazon Must Haves For New Grad Nurses
- Organizational Brain Template for New Nurses
- How to Organize Your 12-Hour Nursing Shift
- Start of Shift Plan for New Nurses
- Tips for New Nurses on Calling the Doctor
And if you’re working nights check these out:
- What Do Night Shift Nurses Do? An Hourly Survival Guide
- Adjusting to Night Shift
- I’m a Night Shift Nurse, What Should I Do with My Days Off?