How to give report.

  1. I just graduated as an ADN and am working as a "nurse tech" until I take the NCLEX. Throughout school and since I've been working in this position, I've seen nurses give report many times. In this time, I've yet to see any discernable pattern for how to give report or what information needs to be conveyed.

    It seems to me that you would want a standard format but I've yet to see it.

    Cleveland Clinic system seems to think the same way as they have (within the last year) tried to get the nurses to give report using the "SBAR" system (adopted from the Navy). SBAR stands for Situation, Background, Assessment, Reccommendation. As far as I've seen, the nurses just toss the SBAR forms aside and continue to do however they feel is best.

    The really funny thing to me is that, with all the charting nurses do, you would think that the nurses charting would form a basis for giving report. After all the nurses chart is supposedly a chronicle of what has gone on with that patient over the last 8-12 hours right? But I've NEVER seen the patients chart used in giving report.

    Now I'm just a new grad so what to I know but it seems like giving report could be more organized and standardized. What I've seen looks to me like a relatively ineffective nursing ritual rather than an actual conveyance of relevant patient information.

    What do you experienced nurses think about all this?
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  2. 12 Comments

  3. by   NotReady4PrimeTime
    In our unit the chart is most definitely used in report. We do a head-to-toe in-depth system review at each change of shift, starting at the head, of course. We refer to our flow sheets for things like all our invasive pressure measurements, vital signs ranges, fluid balance, ventilator settings and blood gas results. The progression is head, heart, lungs, gut, urinary tract, skin, infection and psychosocial. Drips and meds are included in the system they most fit into (sedation, anticonvulsants with neuro; pressors, inotropes with cardiovascular, bronchodilators with respiratory, etc). While we're discussing each system any events relating to that system will be relayed, such as, "At about 1330, she had a brief dip in her BP to a systolic of 49, for which we gave 5 per kg of albumin with good response". I perhaps go into too much detail, but there are always things I wish I'd known about, and I think about that when I'm telling the next shift about things.
  4. by   Piki
    I feel I'm getting better at doing report but I still feel like a boob at times. lol We tape our report but sometimes have to give person to person report (I like that better, as they can ask questions and I can answer, and get immediate feedback)

    We do similar as what janfrn said. I actually use my pt worksheet that I created to work off of. Give pt name, room #, admitting dx, admitting dr, consult dr and then give a brief head to toe assessment, then go into pertinent labs, vitals, prns given and for what reason, and changes in orders and outstanding things to monitor/do.
  5. by   november17
    ours is sort of standardized in the fact that we use a kardex. However we don't really go into too much detail to save time (I'll be darned if I'm going to stay over late giving inpertinent information). Generally we discuss any variances (vitals, labs, or tests outside normal limits, or any other pertinent problems), a short history, the last BM, what works for the pt to control pain, activity level/orders, the latest orders in general, and what the discharge plan is. Sometimes things get overlooked or forgotten and it isn't that big of a deal, since it is easy to look things up in a chart if necessary. I guess the thought of having to give/get report can cause anxiety but at the same time once you get used to doing it several times a day when you work you'll realize what the next nurse will care about and what they won't.
  6. by   deeDawntee
    You are absolutely right! There seems to be as many different reporting styles as there are nurses. I don't care how it is done, as long as I get what I need to know to carry on good patient care.

    You will get the nurse who will tell you EVERYTHING that happened on her shift, all the history, every nuance of family dynamics etc., etc.
    I think it is important to be really tolerant of each other during report. It can be a very frustrating experience!

    I try to give my report in the same way each time, by following my report sheet, but sometimes there is an acute situation occurring that needs to be reported on first, because it is still being attended to...in that case you do the best you can while you are speaking to the MD etc, to fill in the blanks.

    Sometimes, the nurse coming on has already had the patient for a shift or two and in that case your report can be a lot shorter.

    You do the best you can. I have been known to call the nurse when I got home, because I forgot something and that happens once in a while to everybody.
  7. by   David's Harp
    I was so glad to see this thread started, as giving report has been one of the hardest things I've done yet! I'm five weeks into orientation, and I may have given one or two patients' worth of reports that were halfway decent, where there were no "uhh...I'm not sure...good question!"-type moments. I swear I don't know to where my brain wanders off when it comes to the end of the shift - maybe it's on the early train home or something...

    I think I'm getting better at, throughout the shift, gathering all the background info I'll need (which was either missing in report or which I just didn't understand well enough), as well as info about the "plan of action" for each pt. (which can be tricky to tease out of md's - I'm getting better at just out-and-out asking them when in doubt).
    SBAR makes perfect sense to me, and I've heard lots of reports given before as a student, but doing it myself has been a whoooole 'nother animal.

    Anyway, not intending to threadjack here, but I'll be watching the responses here to see what the more experienced folk add to it.
  8. by   Salesman217
    Quote from janfrn
    In our unit the chart is most definitely used in report. We do a head-to-toe in-depth system review at each change of shift, starting at the head, of course. We refer to our flow sheets for things like all our invasive pressure measurements, vital signs ranges, fluid balance, ventilator settings and blood gas results. The progression is head, heart, lungs, gut, urinary tract, skin, infection and psychosocial. Drips and meds are included in the system they most fit into (sedation, anticonvulsants with neuro; pressors, inotropes with cardiovascular, bronchodilators with respiratory, etc). While we're discussing each system any events relating to that system will be relayed, such as, "At about 1330, she had a brief dip in her BP to a systolic of 49, for which we gave 5 per kg of albumin with good response". I perhaps go into too much detail, but there are always things I wish I'd known about, and I think about that when I'm telling the next shift about things.
    Do you work in ICU? I did my internship in ICU and the details you cover in report reminded me of the type of info that ICU nurses were always discussing versus what the med/surg nurses find relevant.
  9. by   NotReady4PrimeTime
    Quote from Salesman217
    Do you work in ICU? I did my internship in ICU and the details you cover in report reminded me of the type of info that ICU nurses were always discussing versus what the med/surg nurses find relevant.
    Ummmm, yes I do. At least that's what it say in my profile! I know what you're saying about the relevance thing... when I'm giving telephone report to the floor nurse when I'm transferring a kid out I can almost see the other nurse's eyes glazing over as I make my way through the systems.
  10. by   Lynda Lampert, RN
    Off the top of my head for med/surg tele, this is my order:

    Name/ doctor/ age
    Consults
    History highlights
    Most important thing about this patient
    New orders this shift/ day
    Head to toe including: orientation, edema, pulses, tele, breath sounds, heart sounds, surgical incisions, chest tubes, jps, pacer wires, abd quality, abd sounds, bm and voiding issues, heplock info and date, ivf, pca and pain meds, level of dependence, abn vital signs, abn labs.

    I try to check all of my charts before I go into report so that I know what I'm talking about. However, I sometimes get in there and don't know something and have to apologize on tape. At least I'm amusing. Just tonight I couldn't remember if one of my seven had a foley in. Gee, I felt like a HUGE idiot over that one, but I found out and clarified in updates.

    I'm much, much, much better than I used to be, though.

    Iona
  11. by   lilcajunnurse
    we have CPSI so at the end of each shift when we print our nursing notes out a summary of the last 24 hours comes out with it. With highlighted details of the last 12 hours (our shift). We perform walking rounds with highlights given then enter the room where the new nurse is introduced and iv site and all other tubes are checked for dates and stat locks and patency. Our patients love it. Of course, one downfall, in the hallway you have to be careful not to mention names. (HIPPA) Hint---on back of summary you was given at your start of shift-write everything for that pt. the summary holds. labs, diet, activity, dr name, diagnosis, meds, prn meds given on last 12 hours, and the mad-act or card ex
    Last edit by lilcajunnurse on Sep 21, '07
  12. by   David's Harp
    Quote from janfrn
    Ummmm, yes I do. At least that's what it say in my profile! I know what you're saying about the relevance thing... when I'm giving telephone report to the floor nurse when I'm transferring a kid out I can almost see the other nurse's eyes glazing over as I make my way through the systems.
    See, I'm orienting on a tele floor and, while a lot of the more experienced nurses there advise me to "cut to the chase", so to speak, I love those details and feel I'm coming up short when I don't have them all together. I hope I can get that level of comprehensiveness together while upping the patient-load, though obviously the specific care won't be as detailed as it won't be necessary, you know what I mean?

    This may read as starry-eyed student-talk to some, but it's important to me, and I'm not interested in any us-versus-them stuff w/ the units, especially w/ the CCU being about a hundred feet away!

    -Kevin
  13. by   David's Harp
    This may read as starry-eyed student-talk to some, but it's important to me, and I'm not interested in any us-versus-them stuff w/ the units, especially w/ the CCU being about a hundred feet away!

    -Kevin
    Alright, that last part looks a bunch more defensive than I intended it. Read with caution! :uhoh21:
  14. by   cherokeesummer
    I'd be interested in learning things about this too, I need to read through the posts but I will work on it!

    In the hospital where I just started they use SBAR. I don't understand some things though - its a NICU and we give the history of the parent every time too, which sometimes seems repetitive but I guess it is all necessary and valid too.

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