For CNAs etc.

Nursing Students CNA/MA

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One thing that keeps coming up on my unit is the lack of communication to the aides regarding the patients. The aides give each other a quick verbal report, but things get missed because they were never told something in the first place. I am thinking of making up a little report sheet for my pts to give to the aides to make things a little easier/safer.

As an aide, would you like this, and what types of information would you like? Open to other suggestions as well!

Thanks much!

Specializes in Acute Care, Rehab, Palliative.

Where I work the aids are expected to sit in on our change of shift report so they don't miss anything. They also have to give each other a verbal report when they are leaving.

We have a report sheet that has a space for each patient and all staff (aids and nurses) write on it.If the aid needs to know what was going on with a patient the previous shift they can read the sheet if they missed it in report.

We have a sheet that the nurse fills out each shift that indicates if the pt is a finger stick, weight, needs specimens, is incontinent, has a foley or ostomy, diet, activity orders, how frequent vitals are to be done, if the pt is in isolation and why as well as any other info the nurse wants to include. In addition to that, they do their own verbal report and walking rounds.

Specializes in LTC.

We get a report from the off-going CNAs and then another report from the nurse, usually right before or right after breakfast. Our report sheets consist of the person's name with a big blank line after it. We note who got MoM, supps etc and if they had results. That way the next shift knows who to look out for in that area. If there were any falls, new bruises or marks, unusual behaviors, labs drawn (so the bruise from that isn't a surprise), appointments, etc or if someone's bed was changed, we write that. Someone also will sit there while the nurse is giving report and write down what she said so we can pass it to the next shift. We have no problems doing it this way, but then again we are LTC so we know all the residents. The only problem we ever have is if one shift includes "complaints" in the report (ie "3rd shift asked us to pass it along to you guys that you never replace the trash can liners and they're getting annoyed, so they want us to tell you to do that")- usually that kind of thing mysteriously never gets passed on. lol.

Our rehab halls are a little different since the turnover is a lot higher and people's care plans are updated frequently. Each shift uses a paper to write down diagnosis, intake, output, bowels, diet, ambulation program, and assist level, plus anything else that needs to be passed on. This information gets checked against the care plan book so it's definitely updated. When you come in the previous shift has your paper started for you- name, room #, diet, and the newest PT program info. During your shift you write in the meals, intakes, outputs, bowels, and how far they walked. That seems to work really well too.

At the last ltc place I worked at they said that we were to leave at our end time and not give report. Well, I stayed anyway and at least gave a verbal report. It was rare that I would leave without giving report. The last thing that I want to happen is to have someone on the toilet and then leave with the next shift not knowing. We had no idea how got MOM or supp it was just a crap shoot. Thank goodness I do not work there anymore and I hope that I will not have to work in a place like that again.

I like to be aware of certain medications the patients/residents are taking such as rifampin or Pyridium so that it will not come as a huge shock when I see that their urine has a reddish-orange tinge.

I also like to know if they have any infections such as MRSA, Herpes zoster, or HSV 2 or are suspected of having one such as C. diff. I always use universal precautions, but there are times when it is helpful to know anyways.

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