Nursing Handover Report

Date: [Insert Date]
Time: [Insert Time]
Outgoing Nurse: [Your Name]
Incoming Nurse: [Recipient’s Name]
Unit/Ward: [Unit/Ward Name]

Patient Information

• Patient Name: [Patient’s Name]
• Age: [Patient’s Age]
• Diagnosis: [Patient’s Primary Diagnosis]
• Room Number: [Room Number]
• Admitting Date: [Admitting Date]
• Code Status: [Code Status, e.g., Full Code, DNR]

Current Condition and Vital Signs

• Vital Signs: BP [Insert BP], HR [Insert HR], Temp [Insert Temp], RR [Insert RR], O2 Sat [Insert O2 Saturation]
• Pain Level: [Insert Pain Level on a Scale of 1-10]
• Current Symptoms: [Insert symptoms like pain, nausea, etc.]

Medications

• Medications Given: [List recent medications and time of administration]
• Next Scheduled Medications: [List medications and times due]
• Allergies: [List any known allergies]

Treatments and Procedures

• Ongoing Treatments: [List treatments like IV fluids, dressings, or oxygen therapy]
• Upcoming Procedures: [List scheduled procedures like scans, surgeries, etc.]
• Recent Changes: [Any significant updates such as new medications or care plans]

Diet and Activity

• Diet: [Insert current diet, e.g., NPO, liquid diet, soft diet]
• Activity Level: [Insert mobility status, e.g., bed rest, ambulatory, assist needed]
• Fluid Intake/Output: [Note any fluid restrictions or significant outputs]

Special Instructions

• Instructions: [Any important care instructions, precautions, or monitoring requirements]
• Family Communication: [Insert notes about family involvement or communication if necessary]

Discharge Plans

• Estimated Discharge Date: [Insert date if applicable]
• Discharge Instructions: [Insert any pending instructions or concerns]

Additional Notes

• General Remarks: [Insert any other relevant information about the patient’s condition or care]

Outgoing Nurse: [Your Name]
Incoming Nurse: [Recipient’s Name]