SBAR Report: Your Guide to Quality End of Shift Reports

• Learn the basics of an end of shift report, including the SBAR Report method, and what is included in the reports. 
• Know the benefits of effective end of shift reports such as increased productivity, communication, and effectiveness in patient care. 
• Review the key methods that keep end of shift reports standardized, detailed, and easy to read.

Handing over patient care at the end of a shift is an important aspect of nursing care. Effective communication is imperative and is used to transfer patient information from an outgoing nurse to the incoming nurse who will be responsible for continuing patient care. The detail and quality of the end of shift report directly affects the quality of nursing care the incoming nurse provides to patients.  

Basics of an End of Shift Report

An end of shift report details a patient’s current medical status while under a nurse’s care. When a nurse finishes their shift, they take a few minutes to document the patient’s health status so the incoming nurse has current information in order to be successful on their shift. The report includes: 

• Patient’s name 
• Current medications and newly prescribed medications 
• Allergies 
• General medical history 
• Pain levels, if any pain medication was given, and the patient’s response  

What should be included in an end of shift report? 

The policy and template used for end of shift reports will vary by facility and specialty; however, the following is a general guide for end of shift reports as a nurse: 

• Employee details: This is important for record-keeping purposes and may include your name, employee number, and the department in which you work.  
• Patient information: List details such as the patient’s name, room number, age, diagnosis, medical history, and medications they are taking. If they are taking several medications, list the medications that apply to the reason the facility is giving them. 
• Assessment: Provide a complete assessment of a patient’s current physical status. Many nurses prefer the head-to-toe technique and list the conditions of the patient in a top-down order. If a patient was experiencing pain and you administered an ordered pain medication, make sure the incoming nurse is aware so they can reassess the patient’s pain level and give another dose of medication, if needed, at the appropriate time.  
• Labs & diagnostics: It is helpful for the incoming nurse to know all lab and diagnostic tests that the patient has received while in your care. 
• Changes to medication or care: Record any changes to a patient’s medication regimen or plan of care so the incoming nurse knows exactly what to give the patient while on duty.  
• Unfilled orders to be continued on the next shift: List any pending lab or diagnostic tests that the incoming nurse is in charge of completing while the patient is in their care.  
• Evaluation: Give your overall analysis of the patient’s current status. Include any abnormal occurrences the incoming nurse needs to be aware of. In long-term care, you can also note any new illnesses, symptoms of concern, or a transfer of a patient from the facility to emergency care. 

Benefits of an End of Shift Report

End of shift reports are vital to nursing care because it helps the incoming nurse understand how to best care for current patients. The end of shift report allows the incoming nurse to quickly review a patient’s medical history, allergies, and best course of action to take in case of an emergent situation.  

The report allows for a smooth transition from one nurse to the next, as well as: 

• Provides extensive background information to increase the productivity of each incoming nurse’s shift. 
• Saves time by providing pertinent information with the most up-to-date updates for each patient. 
• Increases communication across the nursing staff. 

Key Methods of End of Shift Reports and the SBAR Report Method

• Use a standard template: It is important that all medical personnel use the same template when creating their end-of-shift reports. This ensures the same information is present every time. It can also reduce errors and is a more effective arrangement for both incoming and outgoing nurses. It is more beneficial for the safety and health of patients.  
• Fill out necessary details: Regardless of the elements on the reporting sheet, take your time when filling out the report. Give yourself enough time before the end of your shift to fill out the report. Relay the information to the incoming nurse and give them time to ask questions before you leave. Each section of the report is important to the person taking care of the patient when you leave, so being thorough can help the incoming nurse deliver appropriate, individualized care. 
• Consider the SBAR method: There are a few methods nurses can use when explaining information in the end of shift report. One of these is the SBAR method, which documents situations, backgrounds, assessments, and recommendations. It allows the new nurse to ask questions before the current nurse leaves. Medical professionals use SBAR to improve communication between staff members. If you need a reminder; SBAR stands for the following:
  • Situation: Explain what brought the patient into the facility and why they require medical intervention.
  • Background: Give any relevant background information related to the situation that brought the patient into the facility. This can include their current medical status and history.
  • Assessment: Based on your time with the patient, their medical history, and any assessments completed under your care, give an analysis of the diagnosis.
  • Recommendation: Recommend next steps for when the patient is in the care of the incoming nurse. List the steps, describe their urgency, and list any upcoming tests or labs that the nurse should request. 

The Bottom Line

As a nurse, you should give yourself adequate time at the end of your nursing shift to fill out a complete and detailed report for your patients. This will help you ensure that all essential information is effectively relayed to the incoming nurse. By knowing what has previously occurred in a patient’s treatment plan, the incoming nurse can proceed with the correct steps to contribute to positive health outcomes and increase overall patient satisfaction. 

Read More