Nurse Bedside Shift Report Audit

Audit template for evaluating bedside shift report quality, including patient introduction, safety checks, pain assessment, plan of care review, and family inclusion.

Patient Introduction

• Nurse introduced self and role to patient
  Observe whether the outgoing or incoming nurse clearly introduces themselves and explains their role at the bedside.
• Patient identity verified using two identifiers
  Verify that the patient is identified using two approved identifiers before report content is discussed.
• Patient included in conversation and addressed respectfully
  Assess whether the patient was engaged in the report, addressed by name, and treated respectfully throughout the interaction.
• Report conducted at bedside or in patient presence
  Confirm that the shift report occurred at the bedside or in the patient's presence unless clinically inappropriate.

Safety Check

• Bed locked and in lowest position
  Observe whether the bed is locked and positioned at the lowest safe height during the handoff.
• Call light and personal items within patient reach
  Confirm that the call light, water, and commonly used personal items are accessible to the patient.
• Fall risk precautions reviewed or verified
  Check whether fall precautions were reviewed, including assistive devices, alarms, or mobility assistance as applicable.
• Lines, drains, and equipment checked for safety and function
  Assess whether IV lines, drains, oxygen, monitors, and other equipment were visually checked and discussed for safety.
• Environment free of immediate hazards
  Confirm that the immediate patient area was free of obvious hazards such as clutter, spills, or obstructed pathways.

Pain Assessment

• Current pain level assessed with a numeric scale
  Document the patient's reported pain score at the time of report.
• Pain location and characteristics discussed
  Check whether the report included pain location, quality, duration, or other relevant descriptors.
• Pain interventions and response reviewed
  Confirm that current or recent pain interventions and the patient's response were discussed.
• Escalation plan for uncontrolled pain identified
  Verify that a plan exists for notifying the provider or taking next steps if pain is not controlled.

Plan of Care Review

• Active diagnosis or reason for admission reviewed
  Check whether the current reason for hospitalization or active clinical focus was reviewed with the patient.
• Current goals and expected outcomes discussed
  Confirm that the plan of care included current goals, expected progress, or discharge-related milestones.
• Medication, treatment, or procedure updates reviewed
  Assess whether key medication changes, treatments, tests, or procedures were discussed during report.
• Pending tasks or follow-up items communicated
  Verify that pending labs, consults, assessments, or other follow-up items were communicated clearly.
• Patient questions addressed or deferred appropriately
  Evaluate whether the patient had an opportunity to ask questions and whether concerns were addressed appropriately.

Family Inclusion and Communication

• Family or support person included when present and appropriate
  Confirm that family members or support persons were included in the bedside report when the patient consented and it was appropriate.
• Privacy and consent respected during family involvement
  Verify that privacy, confidentiality, and patient preferences were respected when family or visitors were present.
• Family questions or concerns acknowledged
  Assess whether family or support person questions were acknowledged and addressed appropriately when included.