[lil' girl]

New Orders, new admission with dx, I&O, behaviors, falls, skin tears all go on a 24 hr report that is on a clipboard on our cart which we go over with incoming nurse. Also if someone is LOA, such as md appointment, out with family, etc.

[TrickieTam]

I work LTC and always give a thorough report and list need to know info to unfamiliar nurses by doing an actual walk through room to room. I feel if you see an actual face with the information it will click in your head. If a resident has decreased condition I let them know if they are full code or dnr, house supervisor on staff, and Dr on call or Hospice care. Critical information is good to know cause it prevents delays in care. if I caled a Dr and he has not responded after many hours of paging (get a lot of this from medical director) I follow oncoming up to speed on reason for call. I hate coming on and a offgoing nurse doesn't tell me why she called the Dr or family and then I am looking dumb cause she didn't chart it in nurse notes! Also give recent lab report information or xrays if any are done, but I usually do a chart check anyway before shift starts. I write everything down on my 24-hour sheet and use it to give info. Organization is key to good communication!

[evilolive]

Things I note in report: Pts on Abx (and their temps), new orders, falls, skin tears/bruises (BIG lately in my facility), changes in mental status or baseline. All other pertinent information is right in the chart or med book. We have a facesheet for each pt. on the med book that lists how they take their meds (so helpful!). On the chart, a red sticker/name tag indicates a DNR, white sticker/name tag is a full code. All blood sugars are documented in the med book, although I will alert a nurse if a BS is low or high. Other than that, I try to think of anything abnormal or unusual and report it off to the day staff.

It also bothers me majorly to see only my notes listed for patients on Abx or 72 hrs post-fall - how am I supposed to know what's happening on the other shifts?!