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by fireflyLPN

Hi all,

I am a new nurse working in a hospital. I have tried to do my best when giving report, like giving them the info that is not included in the Kardex, and major things like: diet, level of activity, inform them of any tests scheduled that day, & info on IVs. Judging by some of the looks I have received I am clearly not doing something right... but when I ask "Do you have any questions for me?". I usually get a no... So I would like to hear from some of you experienced nurses what exactly you like to have included when you receive report from the outgoing nurse.

[MelissaPedsRN]

Originally Posted by fireflyLPN

Hi all,

I am a new nurse working in a hospital. I have tried to do my best when giving report, like giving them the info that is not included in the Kardex, and major things like: diet, level of activity, inform them of any tests scheduled that day, & info on IVs. Judging by some of the looks I have received I am clearly not doing something right... but when I ask "Do you have any questions for me?". I usually get a no... So I would like to hear from some of you experienced nurses what exactly you like to have included when you receive report from the outgoing nurse.

Do not let other nurses dissuade you or change your good habit of giving the best and most thorough report you can. Nothing irritates me more than the incoming nurse showing disrespect by sighing, rolling eyes, ect, when the outgoing nurse is only trying to supply her with the tools needed for effective care and continuity of care. The "annoyed" nurse will be the first one to complain when she realizes she didnt get enough information, or something pertinent failed to get passed on. Be clear and concise, but keep up the good work. I, for one, respect that.

[HappyNurse2005]

I am fairly new, but when giving report i try to include
name, age, doctor, allergies, dx, admission history (what brought them to hospital), pmh, activity,diet, oxygen, iv's/iv fluids, rhythm (tele floor), dressings, any tubes, labs for today/labs for tomorrow, tests/procedures, etc.

[angelique777]

Hi I Work on ICCU step down cardiac telemetry unit......I am a new nurse and I typed up my own report sheet when I started working following an outline of what they do on the unit and modifying it to match my needs.......although this posting does not retain the format of my report sheet I did manage to cut and paste it here for you to see the information.......remember the format of my sheet changed but the basic information that I provide for the report is visible..........hope it helps........getting a good and thorough report is important so that the continuity of care can be provided best..........therefore let me let you know your doing a good job and that is coming from some who is new as well and has an appreciation of nurses who give a thourough report...........I wish you the best on you new career.......take care and be proud of your self

Take care sincerly Angela ses you around




DATE: REPORT SHEET
PATIENT NAME: AGE: SEX: ADMITTED:
DIAGNOSIS: CODE STATUS FC// DNR//DNI ALLERGIES:

COMORBID/HX/PROCEDURES:


HEIGHT
WEIGHT
NEURO:
MENTAL STATUS
LOC
A&OX 1 2 3
ACTIVITY
OOB, BEDREST, AD LIB, COMPLETE CARE, ASSIST, FALL PRECAUTION
GAIT: STEADY /UNSTEADY
ADL’S: USE OF DEVICES, CANE, WALKER, WHEEL CHAIR.
RESTRAINTS: ALL 4 SIDE RAILS, VEST, WRIST , LEGS,
EXTREMITY STRENGTH:
BIL HAND GRASP/UPPER LOWER
VISUAL: PERRLA/VA
EOM FULL/ OR RESTRICTED
HEARING: WNL /HOH






FALL RISK YES OR NO IV DEVICES:
LOCATION/INSERTION DATE/REDNESS
SWELLING/LEAKAGE/PAIN/PATENCY/
TUBING/CHANGES/DRESSINGCHANGES/
BLD OR CLEAN & DRY
AMOUNT INFUSED
OTHER: PICC//CENTRAL LINE//LOCATION:

R OR L HAND//R OR L AC//R OR L FA// # ga.18/20/22
INSERTED:

NS9%
NS .45%
D5%
HEPARIN

CV:TELE PULSE:
NSR//AFIB//AFLUTTER//SB//ST//PACED//VT//VF//PEA//
EKG:
EDEMA:
JVD/PPP/CP/SOB/PALPITATIONS
HOMAN SIGN/PACER WIRES

DAY SHIFT:
TIME: BP HR RR TEMP PO2 PAIN


TIME:


NIGHT SHIFT
TIME: BP HR RR TEMP PO2 PAIN

__________________________________________________ ________________
TIME:

__________________________________________________ ________
ORTHOSTATIC BP: LYING////////////////////////SITTING///////////////////////STANDING
TIME:
__________________________________________________ ________
TIME;

FS:AC/HS OR BIDAY NIGHT
RESPIRATORY
LUNGS:CLEAR
CLEAR/WHEEZING/CRACKLES/RONCHI/
DIMINISHED/RALES
REGULAR RHYTHMIC 12-24 BPM
AFEBRILE OVER 24 HRS
CONGESTION//COUGH//SPUTUM//PAIN
SOB//USE OF O2: 2LNC

GASTROINTESTINAL
ABDOMIN//SOFT//ENLARGED//OBESEE//DISTENDED/ASCITES//TENDERNESS//N&V
BS PRESENT ALL 4 QUADRANTS
BM 24-48HRS(DATE: )
BLEEDING /QUIAC NUTRITIONIET/NPO
NCS/2GM Na/LOW CHOL/LOW FAT
DIABETIC/REGULAR/SOFT/PUREE
TEXTURED/RENAL
AMOUNT://EAT WELL /POORLY//MEETS STANDARD WEIGHT FOR HEIGHT AGE AND GENDER MEETS CALORIE COUNT



NPO@12M YES OR NO
GENITO-URINARY
CONTINENT//FREGUENCY//URGENCY//DYSURIA//
ANURIC//OLIGURIC//DIAPER//VOIDING//
INCONTINENT
URINE OUTPUT
FOLEY SIZE
INSERTION DATE:
SKIN
SKIN INTACT//WARM/DRY//INTACT//REDNESS
SWELLING//DRAINAGE//TENDERNESS
SIZE OF WOUND//APPEARANCE//LOCATION PLAN: TEST:CXR/ECHO/CARDIAC CATH/ DOPPLER/ CT/ STRESS TEST




DISCHARGEPLAN:BARRIER/S/NEEDS/CONSULT
HHA HOW MANY HRS AND AGENCY:


MISCELLANOUS: PLAN:
THINGS DONE ON DAY SHIFT









THINGS DONE ON MY SHIFT





THINGS TO DO:



SGOT PT 1ST 2ND 3RD 4TH 5T
CPK
SG INR CKMB
OTHER RESULT: APTT CKMB%
Mg TROPONIN
Ca

[Zoomer]

I usually go by systems. Start with patient name age diagnosis allergies code status and pmh. Then just a quick system review. I also include the doctors including the consults.
I hate when you are giving report and the person you are talking to doesn't listen to you or starts talking to other people in the room. I got fed up one time with one nurse who frequently looks as if she could care less what you are saying. She started talking to someone else when I was in the middle of a sentence so I got up and left telling her if she had any questions just look at the chart.

[HappyNurse2005]

ok

DATE: REPORT SHEET
PATIENT NAME: AGE: SEX: ADMITTED:
DIAGNOSIS: CODE STATUS FC// DNR//DNI ALLERGIES:

COMORBID/HX/PROCEDURES:


HEIGHT
WEIGHT
NEURO:
MENTAL STATUS
LOC
A&OX 1 2 3
ACTIVITY
OOB, BEDREST, AD LIB, COMPLETE CARE, ASSIST, FALL PRECAUTION
GAIT: STEADY /UNSTEADY
ADL’S: USE OF DEVICES, CANE, WALKER, WHEEL CHAIR.
RESTRAINTS: ALL 4 SIDE RAILS, VEST, WRIST , LEGS,
EXTREMITY STRENGTH:
BIL HAND GRASP/UPPER LOWER
VISUAL: PERRLA/VA
EOM FULL/ OR RESTRICTED
HEARING: WNL /HOH






FALL RISK YES OR NO IV DEVICES:
LOCATION/INSERTION DATE/REDNESS
SWELLING/LEAKAGE/PAIN/PATENCY/
TUBING/CHANGES/DRESSINGCHANGES/
BLD OR CLEAN & DRY
AMOUNT INFUSED
OTHER: PICC//CENTRAL LINE//LOCATION:

R OR L HAND//R OR L AC//R OR L FA// # ga.18/20/22
INSERTED:

NS9%
NS .45%
D5%
HEPARIN

CV:TELE PULSE:
NSR//AFIB//AFLUTTER//SB//ST//PACED//VT//VF//PEA//
EKG:
EDEMA:
JVD/PPP/CP/SOB/PALPITATIONS
HOMAN SIGN/PACER WIRES

DAY SHIFT:
TIME: BP HR RR TEMP PO2 PAIN


TIME:


NIGHT SHIFT
TIME: BP HR RR TEMP PO2 PAIN

__________________________________________________ ________________
TIME:

__________________________________________________ ________
ORTHOSTATIC BP: LYING////////////////////////SITTING///////////////////////STANDING
TIME:
__________________________________________________ ________
TIME;

FS:AC/HS OR BIDAY NIGHT
RESPIRATORY
LUNGS:CLEAR
CLEAR/WHEEZING/CRACKLES/RONCHI/
DIMINISHED/RALES
REGULAR RHYTHMIC 12-24 BPM
AFEBRILE OVER 24 HRS
CONGESTION//COUGH//SPUTUM//PAIN
SOB//USE OF O2: 2LNC

GASTROINTESTINAL
ABDOMIN//SOFT//ENLARGED//OBESEE//DISTENDED/ASCITES//TENDERNESS//N&V
BS PRESENT ALL 4 QUADRANTS
BM 24-48HRS(DATE: )
BLEEDING /QUIAC NUTRITIONIET/NPO
NCS/2GM Na/LOW CHOL/LOW FAT
DIABETIC/REGULAR/SOFT/PUREE
TEXTURED/RENAL
AMOUNT://EAT WELL /POORLY//MEETS STANDARD WEIGHT FOR HEIGHT AGE AND GENDER MEETS CALORIE COUNT



NPO@12M YES OR NO
GENITO-URINARY
CONTINENT//FREGUENCY//URGENCY//DYSURIA//
ANURIC//OLIGURIC//DIAPER//VOIDING//
INCONTINENT
URINE OUTPUT
FOLEY SIZE
INSERTION DATE:
SKIN
SKIN INTACT//WARM/DRY//INTACT//REDNESS
SWELLING//DRAINAGE//TENDERNESS
SIZE OF WOUND//APPEARANCE//LOCATION PLAN: TEST:CXR/ECHO/CARDIAC CATH/ DOPPLER/ CT/ STRESS TEST




DISCHARGEPLAN:BARRIER/S/NEEDS/CONSULT
HHA HOW MANY HRS AND AGENCY:


MISCELLANOUS: PLAN:
THINGS DONE ON DAY SHIFT









THINGS DONE ON MY SHIFT





THINGS TO DO:



SGOT PT 1ST 2ND 3RD 4TH 5T
CPK
SG INR CKMB
OTHER RESULT: APTT CKMB%
Mg TROPONIN
Ca

good googly moogly! that is a lot!!! how many patients doyou have?? I can't imagine doing that on my 4 patients I have (cardiac surgery PCU). That seems like quite a lot to write down, to all fit on one page, for that matter. And do you report off all of that for each pt at the end of your shift???

i've never seen one that long.
wow!
but if it works for you, go for it!!!

[SharonH, RN]

I hate long drawn-out, overly detailed reports. I need:

Name
Diagnosis
PMH only if relevant
Admitting MD
Code status
Mental status
tele rhythm
abnormal VS
report of systems only as they pertain to the diagnosis
mobility issues
social or discharge issues
any special procedures or surgeries planned

keep it brief and to the point. anything else you are supposed to find out on your own anyway. I don't need to know that they have D51/2 infusing into their Lt hand, that they didn't like their meal from the night before, that their daughter visited and stayed for an hour, about your fight with pharmacy to get the meds up, that you gave them Tylenol for a HA, that they asked for 2 blankets, that they had an appendectomy in 1958, that labs or a CXR is scheduled, or allergies(unless unusual).

Conversely, don't expect me to give a life history in report because you want me to give you everything, so you don't have to look. You are supposed to do your own assessment and review the chart. I just need enough to know if there are changes.

[kadokin]

Wow, you new grads are thorough! Good for you! As last poster wrote, sometimes briefer is better, but hey, I'd rather see a newbie err on the side of caution, wouldn't you? And as for you eye-rollers and rude interupters out there(I've been doing this for 12 yrs and still get it from one in particular, sometimes I just want to b***h-slap him, good thing he is 3x my size, just kidding), shame on you! If a reporter is giving 2 much info, ask them specific ?s. Do the same thing if they are not giving you enough. Come on now, we're all adults, let's just drop the jr. high attitude and treat each other w/respect, kay?

[kadokin]

Also, I LIKE getting some things in report that could be found on the chart. I don't know about the rest of you, but I often step out of report directly into a madhouse that does not allow me time to look at every individual chart. Remember, this is real life we're dealing with. I make an effort to report all prn (w/times given) meds from my shift. Yes even tylenol, those o.d. s can be potentially fatal, you know.

[SharonH, RN]

Originally Posted by kadokin

Also, I LIKE getting some things in report that could be found on the chart. I don't know about the rest of you, but I often step out of report directly into a madhouse that does not allow me time to look at every individual chart. Remember, this is real life we're dealing with. I make an effort to report all prn (w/times given) meds from my shift. Yes even tylenol, those o.d. s can be potentially fatal, you know.

With all due respect kadokin, you should not be giving prn without checking the MAR first, thus eliminating the potential for ods. That is definitely the type of thing you should not be relying on report for. But you're right about treating others with respect, you would not believe the childish and hateful behavior I have encountered before with report.