RECAP: What is a Nurse’s Brain?
A Nurse’s Brain, also known as a nursing report sheet, is a term for a sheet of paper that nurses use to capture important patient information and stay organized. It contains sections for key areas like patient history, diagnoses, labs, medications, body systems status, and more.
In part 1 of this video series, Cathy walks through her Nurse’s Brain and how to use it. Using your Nurse’s Brain ensures a seamless end-of-shift report—to your CNA, other nurses, and the doctor or hospitalist. In this video, Cathy explains how to give a good nursing handoff report and improve your nurse-to-nurse communication.
Download Cathy’s Nurse’s Brain template
What is the end of shift report for oncoming nurses?
An end of shift report is a detailed record of a patient’s current medical status. It’s written by nurses who are finishing up their shifts and are then given to nurses who are beginning their next shifts. It should include the patient’s medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
Why is the end of shift report for oncoming nurses important?
An end of shift report allows oncoming nurses to understand the medical needs of their patients and provides a picture of a patient’s recovery or decline within the last several hours. By knowing what has previously occurred in a patient’s treatment plan, nurses can continue to provide care that will result in a positive outcome.
How to use your nurse’s brain to give report to the oncoming nurse
At the end of your nursing shift, you’ll have a short window of time to give a report to the oncoming nurse. During this transfer of responsibility, the oncoming nurse needs to know the most important information about your patients, so it’s your job to give a concise, organized report on each of them. The amount of time you have for each patient's report depends on where you work and the nurse to patient ratio, but it's usually around 5 minutes per patient.
Your Nurse's Brain can function as a nursing handoff report template. If you have kept track of this information using your Nurse’s Brain, it’s easy to quickly transfer the knowledge at shift change.
What to cover in your nurse-to-nurse handoff report
- The patient’s name and age
- The patient’s code status
- Any isolation precautions
- The patient’s admitting diagnosis, including the most relevant parts of their history and other diagnoses
- Important or abnormal findings for all body systems:
- Respiratory: Is the patient on oxygen? If so, how many liters per minute are they getting?
- Cardiovascular: Is the patient on telemetry? Are they on a cardiac drip or heparin drip?
- Neuro: What is the patient’s level of consciousness?
- Musculoskeletal: Is the patient mobile or bed-bound? Can they get up independently or do they require assistance?
- Gastrointestinal & Urinary: Does the patient have any diet restrictions? When was their last bowel movement? Are they incontinent and do they have a catheter in place? What kind of catheter?
- Skin: Does the patient have any wounds or pressure injuries?
- Is the patient diabetic and are blood sugar checks required?
- What kind of IV access does the patient have? Are they getting continuous fluids? If so, which fluid?
- Is the patient on any antibiotics? Are they taking pain medication(s)? If so, when was their last dose?
- Does the patient require certain tests that day? Do they need wound care? Will the patient be discharged during that nurse’s shift?
What not to cover
There is such a thing as too much information. There are some areas you don’t need to give every detail on because they are either not relevant to the admitting diagnosis or something the oncoming nurse can easily look up. Using too much time on one patient will reduce the amount of time you have to give a report on the next patient. In your nurse-to-nurse report, avoid spending inordinate time on:
- The patient’s non-essential comorbidities. Sometimes patients have 30+ comorbidities and it would use all of your 30 minutes to talk about them.
- Every single medication the patient takes. Again, sometimes patients are on a laundry list of medications that the oncoming nurse can and will look up, so stick to the important ones.
- The patient’s specific labs. The oncoming nurse has access to these details if needed.
What if you are the oncoming nurse?
If you are the oncoming nurse, the best way to receive a report is to be punctual and focused. If you are late, it shortens the window of time that the departing nurse can report on patients.
Patient Involvement
There is good evidence that when a patient is involved in their care they experience improvements in safety and quality. Engaging with a patient and their families during a handoff with an oncoming nurse ensures a safe and effective transfer between shifts. It also gives nurses more time with the patients to answer questions and take care of any needs they may have.
Handoff communication in nursing
Giving a focused, efficient report is an important communication skill in nursing. Others will respect the care and organization you put in--which can improve your nursing relationships with coworkers. Giving a good report builds trust, ensures continuity of care, and improves patient safety.
8 comments
You are a blessing! This is my first time working in a hospital as a nurse and I have had already 6 to 7 preceptors and of course one nurse will say one thing the other nurse will say something different and I don’t really learn best that way. I started following one RN at my request and she has taught me so much however, she goes into every single detail to include things that you included are too much information and she has overloaded my brain and today I left my shift thinking “you know what…maybe this is not for me..” but then I decided to give it one more shot and look online and I came across your website. I feel that reading your Instructions and watching your video will make me a much better nurse at reporting to the next nurse…. thank you so much Cathy you are indeed a Godsend!
I appreciate you for this information. I’m a new nurse and observing other nurses give report makes me look so stupid. I will follow these steps and better myself.
Thank you. Your videos are so helpful.
Great video. Thank you
Thank , it helps me a lot .