Change-of-shift report

A change-of-shift report, also known as a sign-out report or handoff, is an essential hospital document that allows a healthcare provider, such as a nurse whose work shift is ending, to transfer inpatient information to hospital personnel on the next work shift who will be caring for the patient. This transfer of information allows continuity in providing care to a patient who has been hospitalized. This report also serves as a venue for healthcare personnel to discuss any changes that the patient might have developed during the most recent shift, thereby summarizing patient progress. One of the most important goals of change-of-shift reports is to reduce the risk of harm to patients by identifying major health issues that require immediate medical attention.

Overview

Previous studies have shown that the utilization of change-of-shift reports plays a major role in patient care because it ensures continuity in healthcare services for the patient. The relaying of information allows healthcare personnel to provide a similar level of care to the patient regardless of time of day or shift. This information may include the time and dosage of medications given to the patient, vital signs such as temperature, blood pressure, and pulse rate, and any changes in the patient’s response to treatment. Change-of-shift reports are essential because they identify any issues that require extra monitoring or treatment during the next shift.

In 2009, the Joint Commission made handoff communication a National Patient Safety Goal (NSPG) for US healthcare organizations accredited by the commission. To meet this goal, healthcare organizations are expected to have a standardized handoff communication process. The process should be completed the same way each time; include verbal, in-person communication; be a two-way conversation that allows staff to ask and respond to questions, and limit distractions and interruptions. Research emphasizes the use of structured communication tools for patient handoffs, such as I-PASS and SBAR, to improve the consistency and accuracy of information transferred between healthcare providers. The Joint Commission has begun transitioning from NPSGs to National Performance Goals (NPGs), which continue to emphasize safe communication practices, including standardized patient handoffs. For hospitals and critical access hospitals, the Joint Commission’s NPG took effect on January 1, 2026.

One issue that has been linked to change-of-shift reports is the venue for discussion of patient conditions during turnover. It is possible that such discussions between outgoing and incoming personnel are performed in the hallway or nurses’ stations of hospitals, where patients, family members, and other visitors could hear the discussion, thus creating a risk to patient privacy if adequate precautions are not taken.

The transfer of sufficient and correct information to the incoming shift of healthcare personnel also poses a challenge. Miscommunication of patient information may be detrimental to the patient, particularly when it involves the administration of the wrong drug, dose, or procedure. It is also possible that the information provided by outgoing personnel may be linked to the wrong patient. To address this problem, bedside shift reporting has been adopted by certain hospitals, which allows the association of specific medical information to the actual patient situated next to them, thereby increasing patient safety. Many hospitals also incorporate handoff communication into electronic health record (EHR) systems, which help standardize documentation and improve the accuracy of information transferred between shifts.

Bibliography

Capek, Justin, Jane Pascarella, and Danielle Wymard-Tomlinson. "Effective Communication at Change of Shift." Nursing 2013 Critical Care, vol. 8, no. 5, 2013, pp. 22–24.

"Digital Shift Change Reports: Transforming Skilled Nursing Care." Sparkco.ai, 30 July 2025, sparkco.ai/blog/digital-shift-change-reports-transforming-skilled-nursing-care. Accessed 13 Mar. 2026.

Friesen, Mary Ann, Susan V. White, and Jacqueline F. Byers. "Handoffs: Implications for Nurses." Patient Safety and Quality: An Evidence-Based Handbook for Nurses, edited by R. G. Hughes, Agency for Healthcare Research and Quality, 2008.

Jeffs, L., et al. "Clinicians' Views on Improving Inter-Organizational Care Transitions." BMC Health Services Research, vol. 13, no. 289, 2013.

"Patient Handoff Example Templates: An Executive Guide to Safer Transitions." American Data Network, 5 Feb. 2025, www.americandatanetwork.com/patient-safety/patient-handoff-template-safety-transitions/. Accessed 13 Mar. 2026.

Pincavage, A. T. "What Do Patients Think about Year-End Resident Continuity Clinic Handoffs? A Qualitative Study." Journal of General Internal Medicine, vol. 28, no. 8, 2013, pp. 999–1007.

Starmer, A. J., et al. "Development, Implementation, and Dissemination of the I-PASS Handoff Curriculum: A Multisite Educational Intervention to Improve Patient Handoffs." Academic Medicine, vol. 89, no. 6, 2014, pp. 876–884.

The Joint Commission. The Joint Commission’s National Performance Goals January 2026. TCPS-US, 31 Dec. 2025, tcps-us.com/GO/dwnld/NPSG_Summary.pdf?iframe=true. Accessed 13 Mar. 2026.

Washington, Tonya. "The Impact of Nurse-to-Nurse Change of Shift Report at the Bedside on Patient Satisfaction Scores and Patient Safety." Doctor of Nursing Practice Project, George Washington University, 2023, hsrc.himmelfarb.gwu.edu/son_dnp/135. Accessed 13 Mar. 2026.