A well-structured Nursing Handoff Report Template is crucial for ensuring seamless patient care transitions between shifts. Here are the essential sections that should be included:
Nursing Handoff Report Template & Example Free PDF Download
Patient Identification
Patient Name: Include the patient’s full name.
Medical Record Number (MRN): Provide the unique identifier for the patient’s medical record.
Admission Date: Specify the date the patient was admitted to the facility.
Bed Number: Indicate the patient’s assigned bed number.
Vital Signs
Temperature: Record the patient’s temperature in degrees Celsius or Fahrenheit.
Pulse: Note the patient’s heart rate in beats per minute.
Respiratory Rate: Indicate the patient’s breathing rate in breaths per minute.
Blood Pressure: Record the patient’s systolic and diastolic blood pressure.
Oxygen Saturation: Specify the percentage of oxygen saturation in the patient’s blood.
Allergies
Known Allergies: List any known allergies the patient has, including medications, food, and environmental factors.
Current Medications
Medication Name: List all medications the patient is currently taking.
Dosage: Specify the prescribed dosage for each medication.
Route of Administration: Indicate how the medication is being administered (e.g., oral, intravenous, topical).
Frequency: Note the frequency with which the medication is given (e.g., daily, twice daily).
Medical History
Past Medical History: Summarize the patient’s significant past medical conditions.
Surgical History: List any previous surgeries the patient has undergone.
Family History: Briefly note any relevant family history of medical conditions.
Assessment
General Appearance: Describe the patient’s overall appearance, including level of consciousness, skin color, and respiratory effort.
Neurological Status: Assess the patient’s neurological function, including orientation, speech, and motor strength.
Cardiovascular System: Evaluate the patient’s heart rate, rhythm, and any signs of heart failure.
Respiratory System: Assess the patient’s respiratory rate, effort, and any signs of respiratory distress.
Gastrointestinal System: Evaluate the patient’s bowel sounds, appetite, and any signs of nausea or vomiting.
Genitourinary System: Assess the patient’s urinary output, any signs of urinary incontinence or retention.
Pain Assessment: Evaluate the patient’s pain level using a pain scale and document any interventions taken to manage pain.
Primary Diagnosis: Indicate the primary reason for the patient’s admission.
Secondary Diagnoses: List any additional diagnoses related to the patient’s condition.
Plan of Care
Ongoing Orders: List any standing orders for the patient, such as vital signs checks, medications, or diagnostic tests.
Pending Orders: Indicate any orders that are awaiting completion, such as laboratory tests or consultations.
Goals of Care: Outline the desired outcomes for the patient’s treatment.
Significant Events
Notable Changes: Document any significant changes in the patient’s condition during the shift.
Interventions: Describe any interventions taken to address changes in the patient’s condition.
Handoff Notes
Key Points: Summarize the most important information for the incoming nurse to know.
Follow-up: Indicate any necessary follow-up actions or tasks.
Design Considerations for Professionalism and Trust
To create a Nursing Handoff Report Template that conveys professionalism and trust, consider the following design elements:
Clear and Concise Formatting: Use a consistent format with headings, subheadings, and bullet points to improve readability.
Consistent Terminology: Use standardized medical terminology to ensure clarity and accuracy.
Legibility: Choose a font size and style that is easy to read.
Color Coding: Consider using color coding to highlight important information or differentiate between sections.
White Space: Use adequate white space to improve the overall appearance and readability of the template.
Customization: Tailor the template to meet the specific needs of your facility and the types of patients you care for.
By incorporating these essential sections and design considerations, you can create a Nursing Handoff Report Template that facilitates effective communication between healthcare providers and ensures the continuity of patient care.
