9.19 : レポートの種類 I: 引き継ぎレポート

A hand-off report, or change-of-shift report, is a systematic process where a nurse shares patient information with the other nurse, taking over the responsibilities for continued patient care.

It ensures consistent communication and enhances patient care coordination among the nursing staff.

The two categories of hand-off reports are written reports conveyed orally and reports recorded in audio or video format.

During patient hand-off, nurses exchange crucial information about patient care. It encompasses a range of critical details.

It includes basic identifiers, including the patient's name, diagnosis, and consulting doctor.

Next, the patient's health status details, such as vital signs, medications, and treatments, are added, followed by any special instructions from the treating provider.

Afterward, instructions on potential risks are included, like high blood pressure requiring close monitoring during the shift.

Also, information on any side effects the patient experiences from medications or treatments is included.

Lastly, updates to the patient's condition since the last shift, like new symptoms, changes in vital signs or lab values, and treatment plan updates, are communicated.