2PM–6PM: Afternoon Preparations, Documentation and Hand-off (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 Now after lunch, we've got a lot of things to consider.

    00:04 If you take a look at this list, we've got a discharge patient, once one leaves, once coming in the door, they're admitting, you may have procedure results returning.

    00:14 You may have to re-prioritize or change the plan of care.

    00:18 Also, if your patient went to surgery this morning, they may be coming back.

    00:22 So we're about midway or in our shift here about two o'clock.

    00:25 These are some common things we're going to have to address.

    00:29 So let's take a look at this first one.

    00:31 So many times with discharging patients, we've got to make sure the physician said it's okay for them to go, we've got all that paperwork we've got to make sure we do.

    00:41 Educating the patient is really important.

    00:43 And guys, this can take some time.

    00:45 Also, you've got a document.

    00:47 And if the patient's going to another facility, for example, we've got to usually call and provide handoff report as well.

    00:54 So all of these points, here are things we also have to consider in or afternoon in regard to our organization of our shift.

    01:02 Now, if someone leaves, it's a pretty good guarantee that you may have a new patient coming in the door or on your unit.

    01:09 So we admit a patient we also have these responsibilities as well, that we've got to make sure we organize our shift around these.

    01:17 So a full initial head to toe assessment's important.

    01:20 And also the patient may have immediate needs that have to be addressed right then.

    01:25 We got to make sure the patient's safe, and also complete any sort of mission pieces that needs to be done at that time.

    01:32 Now next, a lot of times we're going to get like unexpected results, there could be some change in orders, we may have to let the physician know of critical results.

    01:42 So all this guys can eat up your time.

    01:44 So we may have to page for the doctor, we've got to wait for them, they're going to pull us from whatever room we're working in, we've got to communicate with them, put in the order.

    01:54 These are all time things that we have to organize around for our day.

    01:59 And lastly, in our afternoon, anticipate some changes in the plan of care.

    02:04 So this could mean our patient status, hopefully it gets better, but it could decline.

    02:08 We may need to provide reassessments on our patients.

    02:12 Also, a patient may need a different level of care.

    02:14 And this definitely takes a lot of time to coordinate with the other unit.

    02:18 New orders may pop up, patients may have different tests going on.

    02:23 Also, if your patient went to a procedure or to a surgery, when they get back, we've got to take time, check them in and reassess at this point.

    02:32 So guys, we're ending our shift here, we're getting close to the end.

    02:35 And don't forget to make sure you're documenting and everything's up-to-date in the patient's medical record.

    02:41 So if you remember, if we can charge at the bedside whenever possible.

    02:46 Also, about this time again, towards the end of our shift, it's really important to review your charting.

    02:52 So I'm not saying you have to go through every minor detail, just make sure that everything's up to date, that it's accurate, because again, this is a part of the patient's record.

    03:02 Now, also, it's important, it's easy throughout the day that we educate our patients all the time.

    03:08 Many times we actually forget to document this and take credit for it.

    03:12 Make sure you document any education that's provided to the patient.

    03:16 Many times documenting this is actually meeting certain standards for that patient's disease diagnosis.

    03:23 You may also hear something called 24-hour chart checks.

    03:27 Well, it depends on the facility and their policy.

    03:30 But it typically every evening, the charge nurse or the nurse will double-check to make sure appropriate documentation is done.

    03:37 And again, make sure for the next shift, you update the patient's plan of care.

    03:43 Okay, guys, we're about an hour from when we get to go home.

    03:47 This is actually a really important hour.

    03:49 This is the time we're going to get ready for handoff report.

    03:53 If you remember at the start of our long shift, we did something called bedside report.

    03:59 This is the time we need to gather all this information to make sure to let the oncoming nurse know all of the events that happen throughout the day.

    04:07 So here's a few points.

    04:09 Make sure you round on your patient.

    04:11 Don't forget those four P's and make it purposeful.

    04:14 This is important here because any additional needs the patient has, any safety situations that we need to address, we can do this now.

    04:23 Also, here's a common example.

    04:26 Many times when I'm working at a surgical hospital and the patient's just had a back procedure, about this time about 6 pm at night, I usually give them their pain medications if it's allowed to do so per the order.

    04:42 Reason being is this way the patient doesn't have a gap of medications of me leaving and the new nurse coming on.

    04:48 This is also a great time to address any questions from the patient family.

    04:53 And also make sure any of those fluids running are infusions that you check these for volume and document that.

    05:00 And again, all this information is important for bedside shift report for continuation of care.

    About the Lecture

    The lecture 2PM–6PM: Afternoon Preparations, Documentation and Hand-off (Nursing) by Samantha Rhea, MSN, RN is from the course How to Organize a Nursing Shift.

    Included Quiz Questions

    1. Verify that there is a discharge order from the provider.
    2. Provide relevant education to the client and the client’s family.
    3. Make sure the client is aware of their follow-up appointments arranged by the provider.
    4. Document that the client has been discharged and complete charting on the client before the client has left.
    1. “I do not need to conduct a head-to-toe assessment, as the emergency nurse gave me a thorough report.”
    2. “The emergency nurse mentioned that this client has a penicillin allergy. I will make sure that their chart is updated and that they have an allergy wristband on.”
    3. “I received the report from the emergency nurse and made sure to write everything down.”
    4. “The emergency nurse told me that the client is due for their antibiotics in the next hour. I will get it ready as soon as I have finished my assessment.”
    1. Check all infusions and document the volume.
    2. Give any as-needed medications, for example, pain medication.
    3. Complete a final round of all their clients.
    4. Start preparing medications for the oncoming nurse to dispense.

    Author of lecture 2PM–6PM: Afternoon Preparations, Documentation and Hand-off (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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