NURSING SHIFT REPORT

Date and time: [Date, time of handoff]
Unit and bed: [Unit, room, bed]
Giving report: [Nurse name, credentials]
Receiving report: [Nurse name, credentials]
Where given: [At the bedside, or at the station with a bedside check after]

PATIENT AND ALERTS
Patient: [Name, age, pronouns]
Identifiers checked: [Two identifiers, matched against the wristband]
Admitted: [Date, service, and responsible provider]
Code status: [Current order, and where it is documented]
Allergies: [Each allergy and the reaction, or no known allergies]
Isolation: [Precautions and the reason, or none]

I: ILLNESS SEVERITY
Severity: [Stable, watcher, or unstable]
Reason: [One line on why you rate it this way]
Early warning score: [Score and trend, if your unit uses one]

P: PATIENT SUMMARY
Diagnosis: [Reason for the stay or procedure, and day of stay or post-op day]
Relevant history: [Conditions that change care this shift]
Events this shift: [What changed, with times, who you told, and the response]

SYSTEMS
Neuro: [Level of consciousness, orientation, and baseline]
Cardiovascular: [Heart rate and rhythm, telemetry, BP, edema]
Respiratory: [Rate, SpO2, oxygen device and flow, breath sounds, CPAP]
GI and nutrition: [Diet or NPO and since when, nausea, last bowel movement, glucose]
GU: [Voiding or catheter, output, last void]
Skin and wounds: [Incisions, dressings, pressure areas]
Pain: [Score and scale, last dose, and reassessment]
Mobility: [Activity, aids, and assistance needed]
Last vital signs: [Time, temperature, HR, BP, RR, SpO2 and oxygen]

LINES, MEDICATIONS, AND LABS
Lines and drains: [Each device: type, site, date placed, what is infusing, output]
Medications due: [Drug, dose, time, and hold parameters]
Given as needed: [Drug, time, and the effect]
Held or changed: [What, why, and who decided]
Results this shift: [New or abnormal results, and who was told]
Pending: [Test, time sent, and who follows it up]
Scheduled: [Procedures or imaging, with NPO or prep needed]

SAFETY AND FAMILY
Safety risks: [Falls, pressure injury, delirium, aspiration, bleeding, or self-harm, and the precautions in place]
Restraints or sitter: [Type and next review, or none]
Family: [Contact person, what they know, and who may receive information]
Patient's goal: [In the patient's words]
Discharge plan: [Expected date, ride, and teaching still to do]

A: ACTION LIST
To do: [Task, time due, and owner]
Not done this shift: [What, and why]

S: SITUATION AWARENESS AND CONTINGENCY
Watch for: [What could go wrong this shift]
If it happens: [First step, and who to call]

S: SYNTHESIS BY RECEIVER
Read-back: [Receiving nurse's summary of severity, tasks, and contingencies]
Questions: [What the receiver asked, and the answers]
Bedside check: [Patient, lines, pumps, and monitor checked together]
Accepted by: [Receiving nurse, time]