Efficient communication between nursing staff and other caregivers is key to quality of care. Accurate patient information must be provided to each staff member in order to ensure that a patient is receiving proper care and continues to function, recover and enjoy the highest possible quality of care from caregivers. Many effective tools are available for nursing staff to communicate effectively with each other.
Most long-term-care facilities, home-care settings and some hospitals still use a traditional notebook for staff communication purposes. This simple notebook is perhaps the most important tool staff members have for communicating patient issues, management requests and staff concerns. Each staff member enters pertinent information in the notebook for the following shift to read. Pertinent information can include changes in resident status or behavior, new care plan directives and adjustments to diet or routine.
The charting book is common to most health-care facilities. The charting book helps care plan managers and doctors detect changes in a patient's usual pattern. Both mental and physical status may be entered in charting books. Charting entries often include patients' intake and output, medication administration, changes in mood, odd behavior and any other deviations from patients' normal routine.
Handheld Charting Tools
With the growing popularity and affordability of electronic information devices, many health-care facilities have begun using small, handheld charting devices to track patient information. Nurses and nursing assistants can chart patient information such as vital signs, intake and output, medication administration, behavioral changes and activities of daily living (ADLs) immediately, reducing the chance of charting incorrect information or forgetting to chart important information. These tools are especially effective in fast-paced environments where information may be confused or forgotten at a later time.
At the end of nursing staff's shift, the caregivers give a verbal briefing on patient and facility occurrences to incoming staff members. The verbal briefing may include information not given in any other charting tools, such as general mood of residents, pace of activity and any unusual or relevant happenings regarding specific residents or general facility functioning.
Call lights are in place for residents' use when they are in need or desirous of something, but nursing staff frequently use residents' call lights to request help from additional staff. Nursing staff generally use call lights in an emergency situation or when they cannot leave the patient alone.
The acronym SBAR stands for situation, background, assessment, recommendation. This tool helps nursing staff to effectively communicate relevant information to other nursing staff, management or physicians without including unnecessary details. Using this format a nurse can quickly and efficiently describe changes in patient status, how the situation began, the nurse's opinion of potentially harmful factors and a possible solution for approval.