A report is provided to account for anything that is heard, done or seen. It is communication that is shared through spoken, written, or computer-based methods. Common methods for reporting information include patient records, face-to-face meetings, telephone conversations, written messages and computer messages. Documentation and reporting aid in the continuity of care, and are a legal document providing a record of proof of the nursing care provided.
ISBAR is a communication technique used as a framework for delivering patient information between members of the health care team.
Identity/introduction is where you would communicate who you are, where you are, and why you are communicating.
Situation is where you would communicate who you are speaking about and what is occurring.
The background describes what led up to the current situation, and adds context. Information can be gathered from family, friends, nurses or anyone else who knows the patient.
The assessment gives an opportunity for the healthcare professional performing the assessments, usually the RN, to provide their opinion of the problem.
Recommendation describes what you would do to repair the problem. Examples would be to use external resources, refer the patient to a specialist, be assessed by their primary healthcare provider, etc.
Information shared at change-of-shift includes; patients name, room number, diagnosis, and health care provider, irregular data, abnormal findings in your assessment, pain level and management needs, current orders, any changes in medication, diet, or activity level.
Telemedicine refers to remote clinical services through the use of technology to communicate between the patient and the healthcare provider, or two healthcare providers. It enables nurses to receive and provide valuable information about patient health instantly. Examples of telemedicine include videoconferencing, email, and phone calls.
Transfer and discharge reports are done when a patient is moved to another unit or facility, and when discharging. During a transfer and discharge report, nurses report a summary of the patient's health and information to the receiving caregiver so that they can provide immediate care.
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