by MaryCQB

Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's
Thanks

Mary, wow.. that's a lot of information to give in a report.. seems like a lot of it the newer nurses should know to look up themselves.. like meds.. rather than have someone telling them.. just a thought.. as for organization of report.. there are several in our unit that use forms.. and write everything down.. one RN uses the abc's which she likes.. a airway (vent, O2 delivery method), b breathing- RR, c cardiac - rhythm, heart tones, etc, d diet, e electrolytes, f family concerns, g mmm can't remember, h hydration, i integument, l iv lines, but you get the point.. to me it's hard to receive report in this method but.. hey.. different strokes for different folks..

me? i use the systems to organize my report and add iv lines... normally everything else is covered under system.. cuz if i'm talking about cardiovascular and they have low bp then i tell them about drips hanging at that time... etc..

i'm fairly new myself, but i'm working towards not writing report down when i get it.. basically everything should already be written down either in the nurses notes or chart.. so why write it down again? i'm not there yet.. but i'm getting MUCH closer .. one of the super experienced nurses does it this way..and while i'm giving her report orally she's flipping through the chart reading the H&P, reviewing the last 72 hours of lab, orders and progress notes etc. then she is able to assimilate what i've told her..and what she's read and ask some REALLY good questions.. things I would never think to tell her .. anyway.. that's my goal..

Demographic Information Patient 1

RM# Patient 2

RM# Patient 3

RM# Patient 4

RM#
Age Age Age Age Age
Chief Complaint
Reason for Admission c/o & Reason for admission c/o & Reason for admission c/o & Reason for admission c/o & Reason for admission


Principle Diagnosis
Diagnosis Diagnosis Diagnosis Diagnosis
Comorbid Conditions

Comorbid Conditions Comorbid Conditions Comorbid Conditions Comorbid Conditions
Surgical Procedures Surgical Procedures Surgical Procedures Surgical Procedures Surgical Procedures


ALLERGIES
ALLERGIES
ALLERGIES ALLERGIES ALLERGIES
Code Status Code Status
Code Status Code Status Code Status
Episodic Care
Management Episodic Care
Management
(How many days in hosp) Episodic Care
Management
(How many days in hosp)
Episodic Care
Management
(How many days in hosp) Episodic Care
Management
(How many days in hospital)
Discharge Plan or
Barriers to discharge Discharge Plan
Discharge Plan
Discharge Plan
Discharge Plan


HD/ALOS HD/ALOS HD/ALOS
HD/ALOS HD/ALOS
Plan of Care

Generic Pathway

Pending Actions

Variance to plan




Acute Care Management
(Report only significant changes /information)
Assessments Assessments Assessments Assessments Assessments
Mental Status Mental Status
Mental Status
Mental Status Mental Status
Vital Signs
Times: Vital Signs
Times:


Vital Signs
Times:
Vital Signs
Times:
Vital Signs
Times:

Intake and Output
Intake and Output


Intake and Output
Intake and Output
Intake and Output

Skin Integrity

Skin Integrity
Skin Integrity
Skin Integrity
Skin Integrity

Glucose Monitoring FS
FS
FS FS
Consults Consults Consults
Consults
Consults

Specimen
Test
Labs
Procedures
Treatments
Preps Procedures
Procedures
Procedures
Procedures

Medications
IV
Access Devices
PCA
PD Medications
IV
Access Devices
PCA
PD Medications
IV
Access Devices
PCA
PD Medications
IV
Access Devices
PCA
PD Medications
IV
Access Devices
PCA
PD
Nutrition
Nutrition
Nutrition
Nutrition
Nutrition

Activity
Activity
Activity
Activity
Activity

Teaching/
Learning
Special Needs
Isolation
Fall precautions
Restraints
Constant Observation Special Needs
Special Needs
Special Needs
Special Needs


sorry this was actaully a report sheet I made does not copy well on this site do not know how to copy and keep same format so you can see the report sheet

Originally Posted by MaryCQB

Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's
Thanks

I tried to post my form but couldn't paste it....if you send me a private message, I will get an example to you......

I usually just follow our charting...which goes head to toe...I start with important history, then gtts, BP stuff, IV meds, tubes/drains, neuro, cardiac, respiritory, GI, GU, skin issues, family, pain, labs/abgs...short but sweet...

Re: Shift report form

Originally Posted by MaryCQB

Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's
Thanks

OK I HAVE ATTACHED A FORM I JUST MADE BY LOOKING AT YOUR REPLIES ABOVE

Re: Shift report form

Originally Posted by MaryCQB

Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's
Thanks

I work CVICU and am a new grad (6 months experience). I use Dx, PMH, Allergies, Cardiac, Resp, Neuro, GI/GU, skin, etc. (ex: family), IV, gtts, labs, today (what needs to be done for this shift, or leftovers from the day shift). Works for me.

-PT STICKER-
DX Allergy
PMH
Cardiac Resp Neuro
GI/GU Skin etc.
IV Gtts Labs
TODAY:

Re: Shift report form

Thank you for good concise form. It will help me cut down on the rambling some nurses do when giving report. I don't believe I saw a spot for relevant medical history so I will add a row for this info. Thanks again.

Re: Shift report form

I can't find how to attach a file to this but if you send me a private message, I can send you the one i use in word. It puts 2 patients on one page

Originally Posted by MaryCQB

Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's
Thanks

Re: Shift report form

Please note the OP posted almost 10 years ago and never returned.