What should be passed on during shift report? Here is a nurse report checklist to help break it all down. Although there is a lot here, It is still not a complete list and more will likely be added over time. This list is primarily for registered nurses (RNs), but some of it may be delegated to a certified nursing assistant (CNA). Add any thoughts or suggestions in the comments at the bottom of the page.
Disclaimer: This should only be used as a reference. Lots of things are subjective depending on the location, facility, department, and individual. Not everything is always told in an exact order and some things may be omitted completely depending on the case. Some things are passed on from one nurse to the other while other things may be found out by other means such as assessments, notes, and charts.
What is their first and last name? What do they prefer to be called? You typically use mister or misses followed by their last name unless told otherwise.
What is their age?
What is their sex? Any gender preferences? Any hormone therapy?
Do they have any known allergies? What type of reaction do they have? How severe? Do they have an inhaler, epi pen, or reaction medications? Is it drugs, food, latex, etc?
Who is their primary physician? Admitting physician? Attending physician? Is there a physician on call for them? (especially useful on nightshift)
Have they had any previous consults? Did that physician give any additional orders? Do they have any future consults? What are they? When are they scheduled?
What type of admission are they? Med/surg, telemetry, observation, step down, trauma, etc.
What is the reason for admission? What brought them to the hospital? What are the symptoms? Do they have any history directly related to the reason? When were they admitted?
Have they had any procedures done? What are they? When were they done? What are the results? Were they done on this admission or a previous one? Have they affected their quality of life, such as an amputation?
Do they have any more procedures in the near future? What are they? When are they scheduled? Are they prepared for the procedure? Do they need to be bathed? Do they need to fill out an anesthesia questionnaire?
Do they have any incisions? Where are they? Any dressings on them? Do they have orders for them to be changed? How is it changed? What supplies are needed? How often?
What is their mental status? Are they alert and oriented? Any recent changes in mental status? What is their baseline?
Note: If they are completely alert and oriented, some say times 3 and some times 4. Make sure you clarify which it is for that unit. They stand for person, place, time, and situation.
Do they have any wounds? Any skin issues? Were they there before admission? Are there any dressings on them? How often are they changed? Have pictures been taken?
Any additional medical issues? Are they legally blind, deaf, hard of hearing, etc? Anything abnormal found during your assessment? Any abnormal heart or lung sounds? Weak or absent pulses? Weakness or absent extremity movements? Any pitting edema, clubbing, etc.
Are they on a heart monitor? Is it working correctly? What is the rhythm they typically run? Have they had any recent changes in that rhythm or a history of a certain rhythm? Do they have a pacemaker?
Do they require any type of oxygen? What has been their normal oxygen saturation? Are they currently or have they recently been intubated/extubated? Do they have prn breathing treatments available?
Do they have IV access? What type? Where is it located? What is the gauge? When was it put in? When was the dressing on it changed? Do they have any fluids or antibiotics currently running? At what rate? Any restricted extremities?
What type of diet do they have? Are they eating well? Are there going to be any changes in their diet in the near future, such as an NPO order after midnight for a procedure the next day? Are they on any thickened liquids? Can they use straws? Do they take their meds crushed or with applesauce/pudding? Are they a feeder or need assistance setting up meals?
Are they diabetic? Are we checking their blood glucose periodically? How often? What have they been running? Do they have insulin ordered if needed? What is the amount of insulin required to be given? Have they had any recent moments of severe hypoglycemia requiring extra sugar by mouth or IV dextrose?
Do they have any kind of drains such as a foley catheter, CBI, or JP drain? Where are they located? Is it still in place and intact? How much output have they been having? What has the recent output looked like? Is the drain still required? When is it supposed to be taken out?
Do they require tube feeding? What kind? What rate? Is this their goal rate or is the rate supposed to be increased periodically? What type of access do they have? Is it in place and intact? Do they take any crushed meds through the tubing? How much residual do they have? Is the head of their bed at a 30 degree angle or above to prevent aspiration?
How do they ambulate? Are they on bedrest? Do they require bathroom assistance? Do they use any assistive devices? Do they need a bed or stretcher to go downstairs or will a wheelchair be enough? Do they walk around the unit or go downstairs periodically?
Are they incontinent of urine and/or stool? Do they have an incontinence pad or are they wearing an adult diaper? When is the last time it was changed? Do they go frequently? Can they be changed with just one person or do they require the assistance of multiple people?
What is their code status? Are they a full code or DNR? Do they want any measures done to keep them alive? Is their DNR form signed and in the chart? Do they have a living will or power of attorney? Are they an organ donor?
How have their vital signs been? How often are they checked? What is their baseline? Have any of them been abnormal? Do they have any scheduled or prn medications for them?
Do they have any checks that need to be done periodically or more often than the protocol? Do they have neurological, neurovascular, or NIH checks? How often? When was the last one done?
Are they ever in any pain? Where is it? What has it been on the pain scale? Has it been controlled? Do they have any scheduled or prn pain medication? When was the last dose given? Are they receiving any other forms of pain control such as epidurals, patches, ice packs, or heating pads?
Have they had any nausea or vomiting? Do they have any medication for it? When was it last given? When can the next dose be given? Is there a bucket or bag for them to vomit in if needed?
Do they have any special medications? Any that are not in the pyxis? Any from home with a special barcode? Any that need to be refrigerated? Any that need to be brought from pharmacy specifically for that patient? Do they take their meds all at once or one by one? Do they need to be crushed and given with applesauce/pudding?
Do they have anything for DVT prevention? Are they receiving any blood thinners? Are they on a heparin drip? Are they wearing SCDs or teds? Any history of DVT? Any extremities that shouldn't wear any SCDs or teds?
Do they have any abnormal lab values? Have the values been addressed or replaced? Are they on any sort of protocol? When is their next lab draw due? Is it drawn by a nurse or a phlebotomist? Do they have a PICC line or a port that can be drawn from? Any restricted extremities? Do they have an order to check for HIV and if they do, have they filled out a consent form?
Have they received any blood products? Do they require any blood products? Which kinds? How many? What is the rate they should be given at? Is there IV access large enough? Have they filled out a consent form? Do they have cultural reasons that would prevent them from receiving blood products such as Jehovah's witness?
Do they have any specimens due? What are they and why? Is the patient aware of the specimen? Is all of the equipment readily available in the room? Have they already had any collected? What were the results or are the results pending?
Do they have any type of restraints? What kind? Which extremities? How long? Are they on the patient comfortably? Are they connected to the bed correctly? Is the order for the restraints up to date? Has the restraint form been checked off correctly and is there a new form if needed?
Do they have any visitors? Are they family or friends? Do they stay with the patient? Does the patient want them involved in their care? Do they help with their care? Do they need anything to make them more comfortable? Have they given out any phone numbers if they want to be reached?
Are there any cultural needs? Any cultural customs to be aware of? Any traditions that need to be respected? Any beliefs that will affect their care, such as refusal of blood products?
When is the patient supposed to be discharged? Where are they going to be discharged? Who is taking them? Is there any additional tests or procedures to be done or read before they can be discharged? Any insurance or legal issues that should be addressed?
Does the patient have any concerns? Do they have any requests? Is there anything the patient refuses? Are there any personal issues that need to be passed on? Any special needs that are out of the ordinary?