Exchange of essential written and oral patient care information with other care staff at shift change.
Objective:
To ensure quality and continuity of nursing care.
Material:
– Nursing records.
Procedure:
– Review pertinent demographic data including names, ages, and room numbers. – Summarize important past health history. – Identify key medical and care diagnoses and resolved diagnoses, if applicable. – Present information focusing on recent and important data necessary for staff assuming responsibility for care. – Describe the treatment regimen, including diet, fluid therapy, medications, and exercise. – Identify laboratory and diagnostic tests to be performed in the next 24 hours. – Describe health status data, including vital signs and symptoms present during the shift. – Describe nursing interventions performed. – Describe patient/family response to nursing interventions. – Summarize progress. – Summarize discharge plans, if applicable.
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