How to Create a Nursing Shift Report Online

Nursing shift reports include information on what occurred during a nurse's shift. Information such as patient care, medication administration, communication with other health care providers and physician orders are included in a nursing shift report. Creating this type of report can be accomplished online or in a handwritten report. Online reports can be done by logging onto the computer system, accessing the correct information file and entering the information into the file.

Instructions

• 1

  Gather information needed for the report.

  Gather all of the information required for the report. Use information located in nurses' progress notes. Progress notes are written by nurses and include documentation about everything that occurred during the shift for each patient. Physicians' notes are also a useful source of information. They are similar to nurses' notes and also include pertinent patient information. Ask questions to gather additional information needed for the online report.

• 2

  Log onto the computer system using the assigned user ID and password. Click onto the correct program used for creating reports online. Create a new shift report or edit a previously saved report. Ask a coworker or manager to assist if it is the first time you have used the program to create a shift report. If problems creating the online report occur, contact a supervisor or the company's computer specialist for assistance.

• 3

  Enter the report information into the computer.

  Enter the information needed for the report into the program. Put the information for the report into the correct field. Proofread all information after it has been entered to assure accuracy. Use complete sentences whenever possible when writing a nursing shift report. Avoid using abbreviations to prevent errors. Make sure to use the correct units of measurement, such as microgram or milligram, when entering medication doses.

• 4

  Save the information in the report after it is finished in its entirety. Create a filename for each report and click "Save." After the file has been saved to the computer system, it can be accessed for future reference or use. Reports should be saved onto a backup system, as well as the office computer system, to prevent file loss should a problem with the office computer occur. Make sure each report is saved onto the system correctly before closing the file.

• 5

  Log into the system to edit reports.

  Edit information in a report by opening the file. After the report is open, information can be added, changed or deleted. Resave the information when complete. Add an addendum to reports that cannot be changed after they have been saved into the computer system. Be sure to save all information into the system after it has been entered. Save changes using the same filename as the original report or create another filename. Creating another filename allows both the original report and the edited report to be saved into the computer system.