Sample Communications Board Entry

Title- Must include the Unit/Floor and current Census at the time of documentation

Body- Each entry should start with the Room number , residents name and the important information that needs to be communicated.

 

THIS DOES NOT REPLACE VERBAL SHIFT TO SHIFT REPORT OR WALKING ROUNDS

 

Include in the communication board:

 
  • Falls/Incidents/Accidents
  • Residents on ABT
  • Residents on Coumadin/Anticoagulant therapy
  • Recent Admission/Discharges/Transfers-Residents being prepared for discharge
  • Resident going to or returning from appointments, dialysis, out on therapeutic leave, methadone clinic or similar
  • Resident being monitored for change in condition-document what s/s most be monitored
  • Residents being prepared for an exam or similar that requires special diet changes/restrictions (ex. NPO after midnight)
  • Residents on q 15 minute watch, neurochecks, recent wanderguard placement
  • Residents in pain (last dose given)
  • Residents with peripheral and / or central line placements, last and next med order and dressing change
  • Residents on new medications or changes to medication – Ex. new psych med
  • Resident being monitored for abnormal labs/radiology
 

Be sure your documentation is objective, relevant and to the point. Do not include speculative material, inappropriate comments about the resident, family or facility.

 

This is not a part of the resident’s chart and so it does not replace evaluations or progress notes that must still be written. Like with paper 24 hour reports this may be referenced by management and outside agencies for audit.

 

Each box should represent one shift per unit. If there are two nurses working on the same unit, same shift then each nurse may document in the same box or one nurse documents for the entire unit in one box.