NURSING REPORT

What You Need to Include When Writing a

Nursing Report
1. Introduction.

It is important for good clinical communication to have a concise

nursing report. A great report provides an accurate reflection of
nursing assessments to support the medical team to provide great
care.

2. Objective.

To provide a structured and standardized approach regarding

nursing report and documentation. This section will ensure
consistency and improve medical or clinical communication.

3. Definition of terms. Proper documentation and planned report.

This section comprises all written and digital entries reflecting all
aspects of patient care.

4. Process. This is the area where documentation that supports the

process are written down. Plan of care, patient assessment, and
real-time progress notes are some details.

5. Progress note. This is where real-time reports are documented.

Any relevant clinical information is also included such as a change
in condition, adverse findings or events, patient outcomes, clinical
investigations, and other relevant aspects. Don’t forget to close
the report with companion documents. These are patient
identification, nursing assessment, and legislative compliance.