Clinical Progress Report and Shift Handover

What a good one includes

• Clear patient identifiers alongside their current physical and mental baseline to establish immediate context.
• Chronological tracking of raw vital signs, medication administration, and physical assessments completed during the shift.
• A detailed record of specific treatments, wound care, or therapies administered and how the patient tolerated them.
• Explicit callouts of any clinical deterioration, behavioral changes, or incidents that occurred, complete with actions taken.
• A prioritized list of pending lab results, upcoming doctor reviews, or scheduled medications for the incoming shift.
• An update on the patient's progress toward their discharge goals or long-term care pathways.

Common mistakes to avoid

• Including personal opinions or vague descriptions like 'had a good day' instead of objective, measurable clinical facts.
• Failing to clearly highlight pending reviews or overdue interventions, which leads to missed clinical actions during handover.
• Presenting events out of order, making it difficult for the incoming team to understand the timeline of a patient's deterioration.
• Neglecting to record key conversations with family members or instructions left by visiting doctors and specialists.

Frequently asked questions