Documentation and Reporting in Nursing

Reporting communicates patient information to ensure continuity of care.

SBAR (Situation, Background, Assessment, Recommendation) structures effective handover.

Documentation must be factual, accurate, timely, legible, and confidential.

Verbal and telephone orders should be written down, read back, and verified.

Handover (shift report) transfers responsibility and key information between nurses.

Incident reports document adverse events for learning and quality improvement.