Afraid of giving report, need adivse please! - page 2

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... Read More

  1. by   Daytonite
    I've had to tape report for years. Report should be very simply what has happened to the patient on your shift as well as pulling important highlights from the report you got and passing them on as well. Other than a patient's name, doctor and diagnosis, everything that needs to be done for a patient is already in the kardex and the oncoming shift can review that for themselves. I always reported unusual V.S., especially high B/Ps that I had to treat and how I treated it, finger sticks and any insulin given, and amounts of drainage coming out of tubes during my shift. I always reported activity and one time things happening to the patient on my shift, i.e., they had a CT scan, and MRI, was seen by a particular consulting MD who wrote some new orders, their IV had to be re-started, or they finally got out of bed today and walked. I also reported any calls I made to the patient's doc and the response I got back as well as any new orders that seemed important to mention. If there was some big problem with the family that was reported also. Other than that, it is OK to say the everything is status quo with a patient and move on to the next person on your list. If you start reciting what's on the kardex and the med sheets (unless it's something very unusual) you are going to get rolling eyes and criticism from the people listening to your taped reports. Work from your "brains" (report sheet) as you tape, so begin your shift by setting this sheet up so there is some kind of order to it. Mark things on this sheet that you are going to want to report to the next shift about. I used to put information I was going to pass on at the far right side of my "brains". I have a sample report sheet I will e-mail to you if you PM me and give me your e-mail address. Use the "pause" button if you start to get flustered while you're taping and have to stop talking and take a bit of a thinking break before going on. I often "paused" the tape to take a really good look at my "brains" to make sure I wasn't forgetting something about one patient before moving on to the next. If it takes you 1/2 hour to tape what will end up being a 10 minute report, so be it. Ultimately, you have to assess what your fellow nurses want to hear from you, so ask for feedback from the oncoming nurses. Ask them if you are giving them too much extraneous information that you can just eliminate, or if you are failing to report things that they felt are important but you missed. You will get more help from your fellow RNs by doing this than by struggling on your own trying to figure out what you might be doing wrong which adds to your frustration. This is how you will improve and keep peace with your co-workers. This is how teamwork is built. After taping hundreds of reports you will develop a routine and style of doing it and get faster at it.
  2. by   Sassybottom
    Here is how I organize my reports

    1) A*O * ? Temperment
    2) Precautions i.e. DNR/ DNI, Fall Risk, Isolation, Sitter, etc
    3) How they transfer
    4) Pain? Nausea?
    5) IVF/ Saline lock/ location
    6) Cardiology - tele? irregular rhythm?
    7) Pulmonary - supplemental 02, diminished lung sounds?
    8) GI - distended? ng tube?
    9) GU (foley?)
    10) Skin? Ulcers?
    11) Edema? Pedal pulses?
    12) Significant labs? Potassium protocol? Stool/Urine samples needed?
    13) Diet
    14) Who is following the patient, plans for discharge? Anything out of the ordinary that happened during the shift? Febrile?

    This is the rough guideline I use. I don't always include everything i.e., if the patient has no edema and pedal pulses are strong I will not include it but this head to toe assessment helps me organize my thoughts and helps paint a picture for the next nurse coming on shift.
    Last edit by Sassybottom on Aug 2, '07
  3. by   LAOSI1977
    does anyone know any good handbooks on nursing documentation?
  4. by   TX_TeleRN
    Quote from ZASHAGALKA

    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 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.

    ~faith,
    Timothy.

    I concur with Timothy. I used to fumble very badly in receiving and giving reports until I made/use my own report sheet. It helped me be more organized to ensure that I have information on all the systems. In addition to his advice, I usually start my report asking the receiving nurse whether s/he has worked w/ patient before and if receiving nurse has had a chance to review pt's chart. That way, I can go faster on some things, and slow down on reporting pt's change of condition instead.

    We use computer charting at our place, so I prefer to give my report at a computer while having access to pt's chart. This allows me to show pertinent information (i.e., critical lab values, orders to be done, PRN meds I gave, etc.) to the receiving RN.

    Although on another post, someone mentioned to leave the "feelings" out. I agree, but if pt and/or pt's family acts/re-acts a certain way, then I make it a point to mention it in my report.

    As for fears of giving report, I would recommend practicing. Tape yourself, or have a peer (at work or nsg buddy from school days) critique your report. I confided in one of my work peers and she worked with me to overcome my fears. By the end of my orientation, she told me how much I have improved and how thorough/efficient my reports have become.

    Good luck to you!
  5. by   lilywater
    Tape reporting is actually not the safest way to give report and part of your nervousness may come from the fact that you are afraid you will miss something that may have not been missed if you were to give a live report and another nurse could ask you questions that may help remind you. Also, if you have a report sheet that would help A LOT. Maybe during the day you can keep a separate sheet with you for things that absolutely need to be reported for patient safety reasons and add these on to your report sheet at the end of your shift if you think you may not be able to recall them from memory. Good luck~
  6. by   annacat
    That is a great idea! I will suggest it at some point where I work. Haveing a pre printed template seems like a good safety measure to guard against human error! Genius!
    Seems like it should be standard everywhere!
  7. by   NurseJill
    Quote from sassybottom
    here is how i organize my reports

    1) a*o * ? temperment
    2) precautions i.e. dnr/ dni, fall risk, isolation, sitter, etc
    3) how they transfer
    4) pain? nausea?
    5) ivf/ saline lock/ location
    6) cardiology - tele? irregular rhythm?
    7) pulmonary - supplemental 02, diminished lung sounds?
    8) gi - distended? ng tube?
    9) gu (foley?)
    10) skin? ulcers?
    11) edema? pedal pulses?
    12) significant labs? potassium protocol? stool/urine samples needed?
    13) diet
    14) who is following the patient, plans for discharge? anything out of the ordinary that happened during the shift? febrile?

    this is the rough guideline i use. i don't always include everything i.e., if the patient has no edema and pedal pulses are strong i will not include it but this head to toe assessment helps me organize my thoughts and helps paint a picture for the next nurse coming on shift.
    definitely include code status!
    i always appreciate the plan for that shift coming on, i.e. any tests that the pt needs to leave the floor for (ct, u/s, mri), especially when they're on the vent, it helps to know these things so you can prioritize your day.
  8. by   cherryames2008
    We do the live, face-to-face reports. My orientation was 5 months and I don't think I did my own complete report for at least the first two months. My preceptor was way to nice and I was a nervous wreck.

    Even now, a year later, I still feel like half of my reports go well and half are not as great. It's hard in the first year of nursing. If you get a crappy report or super complicated patient (or both), then you feel like you have to catch up throughout the shift with figuring out what's wrong with the patient and what you're supposed to do.
  9. by   iheartnursing21
    I'm a GN, just finished my third day on orientation. I worked on the floor for 2 years as a Nurse's Aide so I got the hard part of getting used to the floor out of the way. I'm writing because my preceptor on my second day asked me if I wanted to tape on one or two people and I quickly said no. Like most, I was terrified, of talking into a recorder and not forgetting anything important. Also, my preceptor said I wouldn't be taping for quite awhile and this was only my second day. Then I thought, I'm never going to get anywhere if I don't start now. So like planned I taped on two patients. I finished and was so pleased with myself that I had actually done it and well for the most part with a little help. Today I went in and I said, I'd like to tape again. So I was going to tape on the same patients as yesterday, and I did. But then I continued and sure enough I had all 10 patients taped on. So for anyone else just starting like me, don't be nervous, its really not that bad, RELAX, you can do it. Good Luck
  10. by   NC Girl BSN
    Quote from iheartnursing21
    I'm a GN, just finished my third day on orientation. I worked on the floor for 2 years as a Nurse's Aide so I got the hard part of getting used to the floor out of the way. I'm writing because my preceptor on my second day asked me if I wanted to tape on one or two people and I quickly said no. Like most, I was terrified, of talking into a recorder and not forgetting anything important. Also, my preceptor said I wouldn't be taping for quite awhile and this was only my second day. Then I thought, I'm never going to get anywhere if I don't start now. So like planned I taped on two patients. I finished and was so pleased with myself that I had actually done it and well for the most part with a little help. Today I went in and I said, I'd like to tape again. So I was going to tape on the same patients as yesterday, and I did. But then I continued and sure enough I had all 10 patients taped on. So for anyone else just starting like me, don't be nervous, its really not that bad, RELAX, you can do it. Good Luck
    Wow, you have 10 patients! I am super busy with 5. Your doing well!
  11. by   iheartnursing21
    Yes actually at the most we have 11 patients with 1 RN and 1 LPN. We do pod-nursing so its helpful to have a partner. Thanks for saying I'm doing well
  12. by   NC Girl BSN
    Quote from iheartnursing21
    Yes actually at the most we have 11 patients with 1 RN and 1 LPN. We do pod-nursing so its helpful to have a partner. Thanks for saying I'm doing well
    Oh I see, I have 5 patients by myself. It all makes sense now.
  13. by   NightNurseRN
    I dont like taped reports mostly because the oncoming nurse does not have the chance to ask questions! What helps me give reports as someone else mentioned is just going through each of the body systems. I do it the same way each time, that way you dont miss anything.

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