How can I give a good report?

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.

I keep my census report sheet (that I wrote on during my initial report coming on shift) on a clipboard and add the info as I go-----the pertinent information I know will be needed for the next oncoming shift. I then report off of that sheet to the nurses coming. It's a system I developed 8 years ago when I was a new nurse and it never fails. Keeping this "brain" or "cheat sheet" has helped me give report efficiently and accurately, even during times of absolute insane shifts. Good luck. Once you do find what works, STICK TO IT!

Julie, do remember, it will vary by unit as to what is pertinent in shift report. If you are unsure, ask the experienced nurses (that you trust) WHAT needs be included in report and make sure you address all of those things. The items/informationI would report off on in OB is not even CLOSE to the report you would hear, say, in CCU/ICU or med-surg. You have to know the "rhythm" of each unit to know what best report to give. Best wishes.

My problem is that my days are so crazy that by the time I get to give report off to the next shift, I can't remember half the things that I have to tell the nurse and I wind up leaving stuff out. I try to write stuff down during the day, but it gets really busy and I just can't seem to find the time. Any tips from you seasoned nurses out there?

Thanks,

Julie in NYC

You need to make yourself a report sheet where you keep track of everything You need to stop after each patient to record what you have done. This is important and a part of learning organizational skills. Being organized is not only critical to your patients' safety, but it is also crucial to YOUR OWN license.

I work in LTC so might be quite different from where you work if you're in acute. But I have many distractions and interruptions through out my day, so I have a routine where I stop at certain times of the day (whatever suits me) and fill in my worksheet. In between, I use post it notes for every query that comes up and jot them down then stick them by my workstation. When I sit down to gather all the info up, I have my post it notes there to remind me of all the big and little things and I can prioritise. This way, I don't forget. Once dealt with, I chuck the note away. This works for me. I think the main thing to think about at report is "what does this next shift need to know?" They need to know when the last prn med was given, any assessments you've done, f/ups on assessments, Dr's calls, pertinent labwork etc. They don't need to have long dissertations, for example,they don't necessarily have to know how you did a procedure etc they basically need to know you DID the procedure and the outcome in a short concise way.

Excellent point, betsrn. I can't tell you how often I wake up in the middle of the night and can't remember if I signed off on something or if I told the nurse about an NPO status or any number of things. What do you do, though, if you are being pulled in 6 different directions? You just tell them to wait while you record for yourself what you have just done? Maybe I need to start doing that....

-Julie in NYC

As someone mentioned, construct yourself a cheat sheet that has spaces for everything you need on each patient (designed for the kind of floor you work on). Then you just fill in the blanks (it takes only a few minutes) and bingo, you have your worksheet for your charting as well. It will come to you. Go to others you trust for help in designing this.

What kind of a unit do you work on? I would then suggest that you go to the comparable board on allnurses.com and pose this question to others who work on the same kind of floor you are on.

If you are allowing yourself to be pulled in 6 different directions, then you are not practicing safely. As you gain more experience, you will be able to multi-task more easily. For now, however, do one thing at a time. Jot your notes on your cheat sheet about each patient as you see them: NOT later.

My problem is that my days are so crazy that by the time I get to give report off to the next shift, I can't remember half the things that I have to tell the nurse and I wind up leaving stuff out. I try to write stuff down during the day, but it gets really busy and I just can't seem to find the time. Any tips from you seasoned nurses out there?

Thanks,

Julie in NYC

Julie;

I am a new grad as well, but also worked in hospitals for 15 yrs. What I have done is to ask other nurses how they keep track of everything-what cheat sheets/system do they use-I ask them on the unit, at lunch, etc. Most of them (all, really) are very nice and very glad to share how they keep track of things-even giving me copies of their cheat sheets. The best advice I ever got for giving report was head to toe (Neuro to skin)-and to always, always, give it the exact same way. One preceptor during clinicals had me practice giving report to her over and over again, and I think about it during the day-what's important that I need to share? One thing too, was suggested to me was that while it is import to be thorough, don't drag on and on-or ramble....

best of luck to a co-newbie nurse!

Julie, do remember, it will vary by unit as to what is pertinent in shift report. If you are unsure, ask the experienced nurses (that you trust) WHAT needs be included in report and make sure you address all of those things. The items/informationI would report off on in OB is not even CLOSE to the report you would hear, say, in CCU/ICU or med-surg. You have to know the "rhythm" of each unit to know what best report to give. Best wishes.

Speaking of "rhythm", if you work in a cardiac-telemetry unit, you need to know the cardiac rhythms of your patients.