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| |  Afraid of giving report, need adivse please!
Hello I'm a new RN. I've been a nurse for three months in med-surg and the part of my day I DREAD the most is when I have to tape report. It takes me forever and I feel very anxious. In fact, I'm a down right basket case when it comes to taping report. Can anyone give me any advise whatsoever to help me with this? Do any of you use any pre printed formes that may be helpful to me in the future? Thanks for any advise.
Margaret
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Sep 16, 2005, 07:20 AM
Originally Posted by ImShelly31 Hello I'm a new RN. I've been a nurse for three months in med-surg and the part of my day I DREAD the most is when I have to tape report. It takes me forever and I feel very anxious. In fact, I'm a down right basket case when it comes to taping report. Can anyone give me any advise whatsoever to help me with this? Do any of you use any pre printed formes that may be helpful to me in the future? Thanks for any advise.
Margaret
Below was my advice in a previous thread asking this same question. Go to search, and look up the word 'report' by thread title only and it should give you more ideas from others that have addressed this:
Make yourself you very own report sheet template, make photocopies and keep them on a clipboard so you can jot stuff down as it happens. This helps with charting too.
This is how your report should go, more or less, and I'm sure there's other opinions, but this is how I do it:
Pt, age, allergies, DX, any precautions (fall, seizures, isolation) docs involved, history up to your shift, history/changes during your shift, interventions you did, prn meds you gave, docs you called, important labs, upcoming labs/treatments, any mulitdisciplinary involvement, current lines and drips, diet and how tolerated.
Then up to date assessment:
Neuro
Cardiac
Pulmonary
GI
GU
Integumentary (hadn't used that word in ages, sp?)
If you wonder how to make your own report sheet - start with spaces for the items above plus what others recommend to follow.
If you start by writing the report that you get on the template, then update it as you go along, then all the major things will already be there when you give report, and you'll be less likely to leave anything out.
hope this helps.
~faith,
Timothy.
| | No. 2 |
Sep 16, 2005, 03:37 PM
Originally Posted by ZASHAGALKA Below was my advice in a previous thread asking this same question. Go to search, and look up the word 'report' by thread title only and it should give you more ideas from others that have addressed this:
Make yourself you very own report sheet template, make photocopies and keep them on a clipboard so you can jot stuff down as it happens. This helps with charting too.
This is how your report should go, more or less, and I'm sure there's other opinions, but this is how I do it:
Pt, age, allergies, DX, any precautions (fall, seizures, isolation) docs involved, history up to your shift, history/changes during your shift, interventions you did, prn meds you gave, docs you called, important labs, upcoming labs/treatments, any mulitdisciplinary involvement, current lines and drips, diet and how tolerated.
Then up to date assessment:
Neuro
Cardiac
Pulmonary
GI
GU
Integumentary (hadn't used that word in ages, sp?)
If you wonder how to make your own report sheet - start with spaces for the items above plus what others recommend to follow.
If you start by writing the report that you get on the template, then update it as you go along, then all the major things will already be there when you give report, and you'll be less likely to leave anything out.
hope this helps.
~faith,
Timothy.
Good advice, I have felt my taped reports lacking. And this was just the advice I was looking for.
Adam, RN
| | No. 3 |
Sep 17, 2005, 12:30 PM
 Live reports
Hello. We don't tape our reports. We do them live, which has it's own set of anxiety provoking symptoms. I'm always afraid that I'm going to leave something out, or that someone is going to ask me something that I don't know. Anyway, the report follows a typical patturn:
Pt. name, age, Dr., and Dx. Then it is Allergies, code status, and current assessment. Abnormal labs that have been passed on from the day shift, or that have come in on my shift (I work pms), then I do what I did on my shift.... prns, dressing changes, diet eaten and tollerated, new orders, if I called the Dr. for anything, any changes in condition.... things like that. I end up with the I & Os with IV and PCA amounts thrown in.
There are sometimes when I have the night shift interrupt me to ask questions inthe middle of my report and that throws me off. I'm getting better at asking for questions at the end. If I don't know something, I tell them I don't know. We are all human and there are somethings that we just can't do when we are as busy as we all are. Just try to do your best. That is all anyone can ever ask.
You might try to tape a "fake" report at home and see how it goes. Eventually it will flow a lot easier. I have the sheet that I take report on on the opposite side of the sheet that I do all my work. That way I have all the information together when I give report. It works for me. Hopefully you will find a system that works for you. I've always thought that they more systems that we are exposed to, the easier it will be to find our own.
Hope everything turns out for you. Let us know.
Anna
| | No. 4 |
Sep 17, 2005, 12:46 PM
We give written reports which is so much easier. We have pre-printed forms where we fill in the blanks. They print off automatically at 1600. The patients name, room number, docs, dx, allergies, hx, tx's, meds, diet, IV fluids, tubing change, IV location, just about eveything is already printed. It changes from shift to shift as the nurse charts by computer. The second page is fill in the blank which would be the head to toe assessment, PRN's given, and misc or anything important you need to convey. We have blank copies of the second page and fill it out as the shift goes on. By 1800 I usually just have to staple the first (pre-printed) and second page together. This way the off going shift is still on the floor to take care of the patients during shift change. There are of course occasions when you need to give a verbal report because something has happened that is to long to write out but all in all I think our report works out very well. In 4 years I can only recall once or twice when I've had to call back to the floor to tell someone something I forgot in report. You know that dreaded feeling when you wake up in the middle of the night, did I tell the on coming nurse that? It's a moment we all dread !!!
| | No. 5 |
Sep 17, 2005, 04:54 PM
pet peeve
Hey Y'all
My advise is a lil' hint on how NOT to give report. Please, if you're ever giving report to me, don't tell me all the exciting personal drama in the pt's family or how the Pt made you feel or that the Pt is 'cute' or 'sweet'.
A long time ago I worked in a level 1 t-center in Neuro ICU and we worked 12hr shift/7 on-7 off so you always got a verbal report from the small team leader week after week. She would come rushing in late, flop into a chair---big sigh---lights a cigarette (that's how long ago this happened) and announce 'It's been a H#@$ of a day!!'
The report would go like this: "You should see how his daughter treats her mother! And then she turned around to ME and says 'why is his heart rate so high?'---So I write down "HR up--?high".
"I TOLD her, it's always high like that when you have a FEVER!" So I write down T-up.
Finally I told her: (angry grimace...menacingly soft voice) "Don't tell me the FEELINGS. Tell me the NUMBERS."
Papaw John
| | No. 6 |
Sep 17, 2005, 07:22 PM
this worked for me
Bullets
vitals (bp running blah blah blah down from last shift etc.
lines
IVs- running , bag change due at 8pm, line change with that bag etc
blood products
chemo (bmt floor)
infections
"assessment is negative except" blah blah blah
new orders
counts (bloodwork nadars etc) bmt floor
mobility if an issue - due at blah blah etc.
special equipment /settings vents/ hyp. blankets etc
wounds dressing due at blah blah
new tests/results of any done
pending calls to docs
Any safety issues/gorked out ( I did not say that but you get the drift/big smile) 
Does this help? I tried to cover the assessment and not cover everything written down.
They used to call me speed taper LOL.
renerian
| | No. 7 |
Sep 18, 2005, 09:00 PM
You guys rock! Thank you all for the wonderfl advise! Originally Posted by renerian Bullets
vitals (bp running blah blah blah down from last shift etc.
lines
IVs- running , bag change due at 8pm, line change with that bag etc
blood products
chemo (bmt floor)
infections
"assessment is negative except" blah blah blah
new orders
counts (bloodwork nadars etc) bmt floor
mobility if an issue - due at blah blah etc.
special equipment /settings vents/ hyp. blankets etc
wounds dressing due at blah blah
new tests/results of any done
pending calls to docs
Any safety issues/gorked out ( I did not say that but you get the drift/big smile)
Does this help? I tried to cover the assessment and not cover everything written down.
They used to call me speed taper LOL.
renerian | | No. 8 |
Sep 19, 2005, 06:38 AM
glad to help
IMshelly glad to have helped you.........let us know how it goes.
renerian
| | No. 9 |
Sep 21, 2005, 11:16 PM
Giving report
I am a new grad on a Med-Surg floor and I got anxious about giving report (which in my hospital is taped on the phone -Voicecare). My preceptor gave me the idea of highlighting all the info I needed to give with the highlighter. We print out a sheet on each pt and all of the info is at the top of the paper, so I just fill in my new info in an arrangement so that I can keep track of everything. I also write down the info from the prior shift and if it's still relevant, I just highlight it and give it in my report. At my hospital we have very specific rules about using the voicecare reporting, such as don't report anything that you can find on the Kardex, and only include vital signs if they are abnormal. I still feel as though my reports are a little on the skimpy side, but I was told by one of the resource nurses that I had just enough info in mine. 
Once you get a system down with the reports, it will all get easier 
Rebecca RN
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