How well do you write your nursing report?
In recent times, I have seen so many nursing reports by colleagues, some shared in various WhatsApp groups and it is quite worrisome. These reports look like what anyone could write and you necessarily don’t have to be a nurse to put those together. This has inspired me to pen a thing or two on this.
One striking thing about many of these reports is the obvious lack of professionalism in the first instance of query into the subject matter. A Nursing report that doesn’t reflect Nursing in any way is not a NURSING report. Anyone could write that. In fact, I have seen many other healthcare workers mandating reports these days. Many nursing reports lack nursing diagnosis, nursing actions, and most times, are not written or structured in a professional manner.
Imagine reports like, …. patient slept throughout the night; …..patient met on bed as at resumption time; no complaints throughout the shift; vital signs read thus…..; all patients were duly cared for during the shift and many more…. (All limited to those lines without comprehensive analysis of professional activities).
I can totally understand that being in the classroom and in practice are two different things but we still need to ensure the standard of nursing practice is not compromised. It is evidently clear that the standard of our nursing reports keep dropping due to many reasons like work overload, absence of enforcement of professionalism, lack of supervision, poor attitude of leaders to quality assurance, traditionalism of practice over evidence based dynamism, the informality of handing over as the standard over documentation and many more. Many nurses are yet to understand that our reports as nurses; reflects who we are and should be meticulously written.
Now, how do we ensure that we uphold the standards in our reports?
• Apart from medical terms, make use of nursing diagnosis, nursing actions, nursing process in your reports.
• Seek more knowledge on the use of medical/nursing terms and update self on client assessment.
• Ensure they are well structured, detailed and free of grammatical blunders and reflect the professional assessment that you have done.
• For those who are understaffed and over worked, you can employ the use of guidelines/structured nursing report sheets where you can fill in the necessary details. These can be divided into , medical, surgical, post-operative, pre-operative, gynecological cases etc.
• Depending on the environment, nurses can also think of innovative ways to ensure their nursing reports are always up to the required standard.
• For nursing leaders, employ the reward and punishment model to motivate nurses in standard report writing. As a nursing leader, you must increase your own knowledge first so that the actions of subordinates can be measured against the standard that you have achieved and corrections can be better put by you.
Henceforth, we should refrain from the uncivilized approach of “patients were duly nursed throughout the shift, slept on duty, or vital signs read thus” “concoction” or should I say memory verse.
Always write reports like the professional that you are!
~ Catherine Kuyoro