Nurses are the backbone of the medical community. A nurse cares for the patient when the doctor is not there and is required to create an informative history of injury and care via her nursing reports. Every nurse needs to know how to write a nursing report. Doctors use nursing reports to follow the patient's progress once treatment has been prescribed. More than that, nurses need to learn how to write nursing reports that accurately reflect every action taken on the patient's behalf.
- Skill level:
- Moderately Challenging
Things you need
- Protocol (D.A.I.R. data, assessment, intervention, response or S.O.A.I.P. subjective, objective, assessment, intervention, plan)
Initiate contact with the patient waiting to be treated. Perform prescribe treatments on the patient as the patient requires care for an ailment, injury, or disease. Utilise one of the two listed protocols to write an informative nursing report. Inform the patient of the questions you will be asking and why you are asking them.
Ask relevant questions to incorporate the D.A.I.R. or S.O.A.I.P protocols during every interaction with a patient. Collect the patient's answers and organise the results according to the protocol you use to write a nursing report. Use each piece of new data to complete an informative D.A.I.R. or S.O.A.I.P nursing report.
Transcribe each result of the protocol standard into the patient's chart with a pen, using dated pages inserted in chronological order. The nursing report protocol will keep a record of each piece of information that will be needed to create an informative medical history for the patient during and after a physician or nurse practitioner's care.
Describe to the physician what treatment was given when asked. Write a nursing report that is easily read and organised. so that everyone involved in the care of an individual patient can easily understand the directives and the care that has been given to date.
Tips and warnings
- Be objective when writing a nursing report. Be precise. Understand that doctors and lawyers are who will be looking at your reports to confirm or argue care.
- Write a nursing report that has limited information and find that you will be answering questions you may not have the answer to or an explanation for when asked. Incomplete or inaccurate nursing reports leave everyone at the facility vulnerable long after the care was given.
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