How to remember everything, when giving report?

[SeaH20RN]

I just started in the ER and I know most of us use the computer to chart (we use Cerner) but does anyone keep a "brain sheet" with them? Do you use a "cheat sheet "like you would if you worked on the floor to keep notes on? Or just use pencil and paper? What's the best way to keep organized and preparing for report during transfers or change of shift so you don't FORGET anything on those crazy days. Thanks in advance!

[nurse2033, MSN, RN]

I also just tell the story. What happened, what we did, what we found...

[skylark, BSN, RN]

Try the military 'MIST' -

Mechanism of injury - what happened to them, why they came in

Injury sustained - what you found, symptoms, injuries, etc

Systemics - UK word for vitals and any other significant findings

Treatment given so far.

Follow it with the plan, where they are going next, investigations, etc, and you have pretty much the whole story, and unlikely to miss anything out.

Although its intended for rapid trauma transfers, like helicopter arrivals, it works as a good general structure as well.

[zmansc, ASN, RN]

We use a SBAR form. I think the acronym is Stupid Beyond All Reproach, my nurse supervisor tells me it is Situation Background, Assessment, Recommendations. It's got alot of minutia on the form, that really is hard to fathom someone needs on a form, and I guarantee 99% of it came from the computer. I've taught techs how to fill it out based on reading the pt record in the 'puter. Now that we have it on yet another form, I get to tube that to you and then call you so I can read it to you since you apparently can't read, nice waste of time!

I don't mind giving a verbal report, when I'm actually giving valuable information, and that is what I do. Typically I follow a SOAP structure to my report because that's what I learned when I did EMS and it's what providers use, so I don't see the value in coming up with the same thing only different for nurse to nurse. I don't blabber the stuff that is easier for them to look at on the 'puter, or from the SBAR, or wherever. I don't tell them where the IV is located, if they can't find it, then we have bigger problems than what I say in my report!

[Jasel, BSN, RN]

I usually grab a scrap piece of paper to write down certain info. Usually who the admitting Dr is and the admitting Dx. As well as any relevant/abnormal lab or diagnostic results. If I'm reporting off to the ICU I try to be a bit more specific as they're much more detail orientated up there. For everything else I pretty much just tell them the situation, where IV is placed, AO status, wounds, if meds were reconciled, etc. It really just becomes routine after awhile,

[joe007]

We use Epic in the ER which has an area for the doctor's notes, which includes pretty much all of the labs, scans, diagnoses, history, etc. I give report from this.