Bedside Report Evaluation

Bedside shift reporting is used in many health care facilities to promote a beneficial handoff for both patients and nurses. This type of reporting is an important process in clinical nursing practice because it allows staff to exchange necessary patient information to guarantee continuity of care and patient safety. “Moving the change-of-shift handoff to the patient’s bedside allows the oncoming nurse to visualize the patient as well as ask questions of the previous nurse and the patient” (Maxon, Derby, Wrobleski, & Foss, 2012).

The American Nurses Association estimates that up to 80% of serious medical errors involve miscommunication between caregivers when patients are transferred or handed off during shift report (ANA 2012). In the nursing profession change of shifts require the successful transfer of information from nurse to nurse to prevent medical errors and adverse events (Sullivan, 2010). Research shows that when patients are included and engaged in their health care there is greater potential to lead to measurable improvements in safety and quality of care. The purpose of this paper is to report results of an organized review of the literature which studied bedside reporting in the hospital

Appropriately modified de-identified data for the 56431 attendee at the various clinics was used for this analysis.

Bedside reporting has been shown to improve communication and quality of handoff between nurses. It is also credited to promote patient safety and improve patient satisfaction. Patient satisfaction, patient safety and nursing communication and quality of report from a 32 bed surgical hospital in Dallas, Texas is to be evaluated using various surveys, HCAHPS scores, incident reports, and call light logs. Data will be collected 2 months prior and 6 months following the implementation of bedside report. Scores and communication survey results will be reviewed in this time period to determine increases or decreases from pre-implementation results using traditional nurse-to-nurse report.. The projected goals and outcomes of this project are to increase quality of report, increase patient safety and increase patient satisfaction.

Overall, incomplete documentation and delinquent medical records cause inaccurate reimbursement and results in inaccurate gross revenue to the hospital. It can have a negative impact on the hospital budgeting and financial planning process for the hospital. It is for this purpose that every healthcare institution should be purposeful on reviewing the accuracy and completeness in clinical documentation, no matter the cost. Even though, for most physicians, most of their time is focused on the actual care of the patient and there is little to no time to devote to extensive documentation, it is imperative to understand patient care includes both the one-to-one attention and the documentation of said treatment.

Many current issues and health policies in the health system in America today are impacted by a multitude of healthcare providers. One current issue that has yet to be highly publicized yet impacts all aspects of quality for clinicians is errors in diagnosis. This issue results in various client impacts from economical and additional strain on healthcare, to potential death of patients and social, ethical and potential aspects of neglect (Toker, 2013). Economically the provider’s misdiagnosis can cause the patient substantial cost through repeated tests, procedures or poor outcomes. Misdiagnosis can also cause multiple consults for subspecialties, additional medications, procedures and unanswered questions to diagnosis and results. Furthermore

Each of these subdivisions require different means of knowing and communicating. Nurses may only be expected to know a small amount of information on a wide variety of diagnoses, while a doctor may be expected to know a far larger amount of information on an even wider scale. There are also certain expectations for communicating among and within these subdivisions. Means of communicating within the nursing community is often far different than that of doctors and even so, communication between doctors and nurses. Though these means of communication may differ between subdivisions of the medical community, it is essential that all members are aware of the proper means of communication, as well have enough knowledge about the topic at hand to correctly interpret the information received. With a patient’s life at risk, insufficient means of communication, or a total lack of communication, could lead to further complications, or the ultimate failure -

Nursing provides the highest amount of patient contact care, providing care at the bedside throughout out the patient’s entire stay in the hospital. Fran Roberts, Ph.D., RN, FAAN, makes an excellent point when she describes a nurses perspective of a hospital from the inside out, offering a view that no other healthcare provider can (Roberts, 2014). Dr. Roberts goes on to explain that this unique perspective provides insight that no other board members can bring to the table, such as what it 's like to work short staffed, at what point patient safety becomes compromised, and experiences that no one can offer other than another nurse (Roberts, 2014). With the board commonly consisting of several members of the community as well as physicians, it is helpful with a nurse on the board to

As a nursing student I am taught how to document using special medical terminology, and the importance of documenting, however the article “Stay Out of Court with Proper Documentation” by Sally Austin confirms just how critical it is to be accurate, timely, and unbiased with patient documentation. Proper documentation not only helps keep the patient safe, but just as importantly protects the nurse should a lawsuit occur. Austin’s article defines the legal terms used in the more common lawsuit, negligence, involving nurses and how to avoid them.

Nurse Bedside Shift Report Implementation Handbook Submitted by Manju Bhattacharya Table of Contents Introduction --------------------------------------------------------------------------------------------------------------------1 Overview of the Nurses Bedside shift Report strategy ----------------------------------------------------------------1 - What is the Nurse bedside shift Report tool? ---------- -------------------------------------------------------------------2 --------------------------------------------------------------------------------------------3 Rational for the nurse bedside shift report strategy --------------------------------------------------4 What is the evidence for nurse bedside shift report? Set aims to implement Set aims to implement Nurse Bedside Shift Report -----------------------------------------7 Identify the logistic report for your hospital-------------------------------------------------------------------------------8 Decide how to use and adapt the tools in this strategy------------------------------------------------------------------9 Implement and evaluate the nurse bedside shift Report strategy Report strategy -------------------------------10 Train staff ---------------------------------------------------------------------------------------------------------------------10 Conduct bedside report Conduct shift report----------------------------------------------------------------------------10 Get feedback from patient nurses and family--------------------------------------------------------------------------11 Case Study on Nurse Bedside Shift Report Nanavati hospital -------------------------------------12 References

The patient is reported to have shortness of breath from initial handover between emergency department nurse to ward nurse. With the patient’s history of a chronic obstructive pulmonary disease, their level of consciousness should have been observed frequently to classify the patient had not undergone hypoxia and hypercapnia. Furthermore, evidence between two nurses from the time of 0300 hours to 0500 hours, did not comply. As the attending nurse had said she left at 0300 hours and returned at 0500 hours, the nurse left on standby said the attending nurse had, indeed, made an appearance within that time (HCCC v Jarrett, 2013, 116, 118-121).

When the Hospital Standardization Program established their initial set of minimum standards, one of the prescriptive measures required healthcare organizations to maintain medical records for patient treatment. The necessity of creating, and preserving a detailed account of a patient’s history, laboratory results, and treatment seems rudimentary today. The Hospital Standardization Program made significant advances in enforcing proper documentation. Building on that legacy, TJC strengthened standards involving appropriate medical documentation by including strict timelines for completion. For example, TJC mandates a patient’s History and Physical (H&P) report be completed within 24 hours of admission. Several elements must be included

Galt, K.A., & Paschal, K.A., (2011). Foundation in patient safety for health professionals. Sudbury: Ma. Jones and Bartlett

Communication in nursing is known for its life saving success as well as its greatest flaw in poor patient outcomes. There is always room for improvement and when communication is carried out efficiently, healthcare professionals have reaped the benefits. However, there have been many instances in which nurses have had to learn the hard way of how detrimental communication can be to patient safety. Through research and reviews of literature, the topic of patient safety related to handoff communication among units is analyzed.

Points of care solutions are medical diagnostic testing or documentation done at the patient 's bedside. At my work we us point of care documentation, meaning that the nurses do their documentation in the patient 's room. Research shows that point of care solutions “reduces inefficiencies, decreases the probability of errors, promotes information transfer, and encourages the nurse to be at the bedside” (Duffy&Kharasch, 2010). However, point of care services has been reported by patients to make them feel alienated for their care providers because the nurse 's attention is on their charting and not the patient (Duffy&Kharasch, 2010). This has the potential to “compromise the nurse-patient interaction” (Duffy&Kharasch, 2010). With changes in