1.

Explain about following medical records. a) Change of Shift Report b) Transfer and Discharge Notes

Answer»

a) Change of Shift Report- During each shift, documentation of the patient’s assessment made is done. The “Change of Shift Report” is the communication between the nursing staff during shift changeover periods regarding patient care. At the end of each shift nurses report information about their assigned patients to nurses working on the next shift. A handover report is usually given orally in person or during rounds at the bedside. Reports given in person or during rounds in hospital permit nurses to obtain immediate feedback when questions are raised about a patient’s care.

b) Transfer and Discharge Notes- When a patient is transferred to another facility either temporarily or permanently, a transfer note is written. 

This note may include the following:

  • Reason for transfer 
  • Method of transportation 
  • Person giving and receiving the report 
  • Notification of the patient, including vital signs and treatments in progress.

 A similar note is made when a patient is sent for a test within the same facility. When the patient returns to unit a similar note may be made.



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