FON REPORTING Flashcards
An oral or written exchange of information between health care professionals.
REPORTING
Must be concise and include pertinent information but no extraneous detail.
REPORTING
4 Types of Reporting
-Change-of-Shift Report
-Telephone Report
-Care Plan Conference
-Nursing Rounds
It is a process in which information about a patient is communicated in a consistent manner including an opportunity to ask and respond to questions.
Change-of-Shift Report/Handoff
it allows the oncoming nurse the ability to ask
questions and gain confidence to care for the client.
Face-to-Face Communication
is given to all nurses on the next shift.
COS/Handoff
Key Elements for Effective COS/Handoff Communication
The communication should include the following:
* Up-to-date information
* Interactive communication allowing for questions between the giver and receiver of client information
* Method for verifying the information (e.g., repeat-back, readback techniques)
* Minimal interruptions
* Opportunity for receiver of information to review relevant client
data (e.g., previous care and treatment).
3 Important Features of COS/Handoff
- Two-way Face-to-Face Communication
- Written Support tools
- COntent in handover capture problems and interventions
Relevant Information During a Change-of-Shift Report
-Provide basic identifying information for each client
-For new clients, provide the reason for admission or medical
diagnosis, surgery, diagnostic tests, and
therapies in the past 24 hours.
- Include significant changes in the client’s condition and present information in order.
-Provide exact information on special procedures or medications
-Report clients’ need for special emotional support.
-New orders for the patient
-Priorities of care at the start of the new shift
-Be concise, don’t elaborate on background
-Incorporate verification process.
Sample Handoff Communication Tools
- I PASS the BATON: Introduction, Patient, Assessment, Situation, Safety Concerns, Background, Actions, Timing, Ownership, Next
- I-SBAR: Introduction, Situation, Background, Assessment,
Recommendation - PACE: Patient/Problem, Assessment/Actions, Continuing
(treatments)/Changes, Evaluation - Five-P’s: Patient, Plan, Purpose, Problem, Precautions, Physician (assigned to coordinate)
the
_______ allows for an easy and focused way to set expectations
for what will be communicated and how between members
of the team, which is essential for developing teamwork and
fostering a culture of patient safety
SBAR
SBAR CONTAINS-
S = Situation
* State your name, unit, and client name.
* Briefly state the problem.
B = Background
* State client admission diagnosis and date of admission.
* State pertinent medical history.
* Provide brief summary of treatment to date.
* Code status (if appropriate).
A = Assessment
* Vital signs
* Pain scale
* Is there a change from prior assessments?
R = Recommendation
* State what you would like to see done or specify that the
care provider needs to assess the client.
* Ask if healthcare provider wants to order any tests or
medications.
* Ask healthcare provider if he or she wants to be notified
for any reason.
* Ask, if no improvement, when you should call again.
True/False
In TO The individual receiving the information should repeat it back to the sender to ensure accuracy
True
It is a communication tool that is often used for telephone
reports.
SBAR
Guidelines for Telephone
and Verbal Orders
- Know the state nursing board’s position on who can give and
accept verbal and phone orders. - Know the agency’s policy regarding phone orders (e.g., colleague listens on extension and cosigns order sheet).
- Ask the prescriber to speak slowly and clearly.
- Ask the prescriber to spell out the medication if you are not
familiar with it. - Question the drug, dosage, or changes if they seem inappropriate for this client.
- Write the order down or enter into a computer on the physician’s order form.
- Read the order back to the prescriber. Use words instead of
abbreviations (i.e., “3 times a day” instead of “tid”). - Have the prescriber verbally acknowledge the read-back (i.e.,
“Yes, that is correct”). - Record date and time and indicate it was a TO or VO. Sign
name and credentials. - When writing a dosage always put a number before a decimal (i.e., 0.3 mL) but never after a decimal (i.e., 6 mg).
- Write out units (i.e., 15 units of insulin, not 15 u of insulin).
- Transcribe the order.
- Follow agency protocol about the prescriber’s protocol for
signing telephone orders (i.e., within 24 hours). - Never follow a voice-mail order. Call the prescriber for a client
order. Write it down and read it back for confirmation.
Once the order is written on the physician’s order
form, the order must be countersigned by the primary care provider within a time period described by agency policy. Many acute care hospitals require that this be done
within 24 hours.
