How to do report or get report smoothy for Newbie?

Specialties Critical

Published

Hi fellow ICU nurses,

I am still in my orientation for my unit, week 3. Little background about myself: graduated a year ago and worked outpatient. And then luckily, getting dream job in ICU.

I have some working experience, I am pretty used to communicating well and efficiently with patients especially and other team members in outpt setting. I talked with doctor and PAs all the time at my old job and never really had problems to give or receive messages. However, I found myself having a hard time to give shift report or receive report from other nurses (like ask the right questions and stuff) in house setting.

I wonder it has anything to do with me being so green in general. I think I am still trying to follow the textbook too much and give reports according to h2t assessment? I don't know how to do focus report yet or "get to the point right". Then in order to do that, I'm confused, not sure how to start. My preceptor kept jumping in and taking over from me giving report. She did not do a very good job at teaching me either and assume I should have known how by now. I feel quite frustrated because I know my patient well during the shift but during report time, I appeared to be inadequate and not remember anything. And when talking to MDs, my mind usually just goes blank.... I went to the South after living in CA for the job, and have an foreigner accent. I feel quite insecure at the moment that the differences also make it harder to communicate as well?

Any tips for newbie like me to get improved on reporting? Thanks!

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

Are you giving report in chronological order in every two hour incrememnts? Or are you summarizing the major events of the day and then going by systems? I'd recommend the latter. You don't have to do into a whole lot of detail unless there's been a major change or major event, but you do need to cover the important assessment findings by system, med changes, significant labs and any family or visitor issues. An organized "brain sheet" may help you. Pay attention to how you get report -- how the information is organized and how deeply they go into the systems. That will give you a good starting place.

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Specializes in PICU, CTICU.

When I give report, I start with the patient's history and what brought them in for this admission. Sometimes I go into "overnight events" before I start my system by system report, just to give a little snapshot of what the issues may have been most recently. Then we break it down as follows: Neuro (pain), Cardiovascular (PIVs, central lines, drains), Respiratory, GI/GU (I&Os), Skin, Psychosocial. Ruby Vee's advice about imitating the reports you receive is also sensible. Good luck, don't over-think it...it comes with time. I remember skipping around a little when I was a new nurse too.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

brain sheets.......here are a few.

doc.gif mtpmedsurg.doc

doc.gif 1 patient float.doc‎

doc.gif 5 pt. shift.doc‎

doc.gif finalgraduateshiftreport.doc‎

doc.gif horshiftsheet.doc‎

doc.gif report sheet.doc‎

doc.gif day sheet 2 doc.doc

doc.gif ICU report sheet.doc‎

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

Thanks! I knew I couldn't compete with that!

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I don't have an answer for you but I just wanted to say that I could have written the same post! You are not alone :) I think it just takes time and practice. I'm actually considering taking out a fresh report sheet near the end of my shift and writing out what I want to say at report. That way when my mind goes blank, I'll have something to fall back on.

I wish those preceptors who have a propensity to just take over when we stumble would understand how detrimental it is to the learning process! I need someone to help me, not do it for me, when I get stuck.

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It is getting better. I just need to know the background story a little bit more. I simply don't have time for doing that at the moment. LOL. But it's ok I feel like I am getting faster with time though so when I am handy with other stuffs I will pay more attentions on giving a throughout report.

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You need to know their history, it's part of taking total care of the patient. The best way to get a synopsis is in the H&P and then I read the most current physician notes to find out what has been going on since admission and plans for the pt. I do this quick glance after I verify allergies, check labs, and orders before I see the patient. Otherwise, if family is at bedside and starts asking questions, I feel somewhat prepared to answer them. When i get free time usually in afternoon before 6pm meds, I can sit down and read more notes so I can gather the history for report. I write everything in chronological order of the events during hospitalization and when I give report I list the major events. I also add all of the info to the kardex if it is not already on there so I have it written down to help me when giving report. I also write down all significant events that happened during my shift so that I remember to tell the next shift. I find giving report in a head to toe fashion is easiest for me. Starting with Name, Age, Code status, allerigies, DX, Hx, Significant test results/ events since admission, Neuro status - baseline vs current, Respiratory -vent settings, weaning trials and results, how they sound, CV- rhythm, BP, vasopressor parameters, etc; GU- foley, urinal, etc. How UO has been. If low, what did you give; GI- TF, NGT outputs, etc. Drains- Output characteristic, amount of drainage. Skin integrity. Psychosocial: Family and family dynamics, issues from the shift. I then usually summarize what I did for pt: low H&H gave blood, current H&H, abnormal electrolytes, gave potassium, etc. I also make sure to tell if pt got out of bed, worked with PT, any consults that came and saw pt and what their recommendations and also communicate what the plan of care is for pt. It takes time to get it down, but as long as you write things down, and take the time to prep for report, it will go smoothly.

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Those brain sheets are so handy! Thank you!

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Specializes in ICU.

Does your unit have a standardized report sheet? My best unit had one that a committee came up with and everybody used for giving report. You just went from box to box - name, reason for admission, quick history, allergies, code status, docs, vitals, lines, supports, pulmonary, renal, yada yada yada, road trips.

If for some reason you were picking up a patient and the nurse didn't have time to give you report until later, you could grab the board and have enough to go on.

Even the docs would grab the clipboard and read it! :yes:

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Specializes in ER, Trauma ICU, CVICU.

First off, realize that you aren't going to be able to please everyone. I learned early on what my fellow nurses wanted out of report and I tailored my report to their needs. Some want short and sweet, some want head to toe and every minute of your day.

Here is my basic format when I am giving a patient to a nurse who has not had the patient before:

Name, sex, age, code status, allergies, all physicians seeing the patient, relevant medical history (I don't care about their broken finger 70 years ago), reason for coming in, medical diagnoses, recent procedures and drains or lines present. Then I go into the Head to toe (neuro, cardiac, respiratory, GI, GU, skin), then I go over labs and important meds and drips (including last doses of PRNs).

Many nurses don't want that much info, and that's ok. But, most of the time this format will serve you well in the ICU. If you are confident and don't stumble, most will appreciate the thoroughness this format offers. After awhile you will be able to spout off everything listed here from memory.

P.S. This is back to personal preference...but I hated written reports unless it was absolutely necessary r/t some kind of emergency.

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Specializes in NICU.

Granted, I'm NICU, but...

I try to do report in the same order every time:

Name, Age, Physician, code status

History, complications, procedures

Respiratory support (including ABG schedule/vent weans/chest tubes/ect

Lines, fluids and drips with rates and parameters

Neuro

GI--feeds if applicable, stooling issues, ect

GU--foley/urine output goals

Skin & skin care (wounds?)

New orders and plans for the next couple of days

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