[lmonet82]

what does a good report consist of? i am returning to the acute care setting, and need tips.

[Sisukas]

When I take report, I like to hear just a summary of their problems, system by system, head to toe. If there are no problems with any system, just say so..."no neuro deficits, chest is clear, skin's intact" etc. Then give me a rundown of the events of your shift and any new orders written. Oh, and when you last gave them pain meds. If you give me a copy of the new orders, that's a time saver for both of us. If I have any questions, I'll try to wait until you're done with that patient..I hate to be interrupted. It removes me from my chain of thought.
Basically, shift report is time that belongs to you, and the oncoming nurse shouldn't waste any of it. Things like diet, activity, should be on the care plan and can be written down after you leave. Give the nurse what information you have that isn't on the rand or care plan, try not to complain about doctors or the food in the cafeteria too much, . Be ready to give report when they come on and ready to take report when you come on. They want to go home, too.

[TriageRN_34]

We tape report and here is how I line it up:
1. Room number Pt name and age
2. "pt of __________"
3. "in here for _____________" (if surgery I state date of).
4. All tubes if there ("has a foley, trach and j-tube with jevity, and a wound vac to suction").
5. Diet and activity level.
6. Any interesting facts that have happened like labs or something pending during their shift. I like to keep those last because it is easier to remember if you say them last!

Here is an example. "Hi this is ____ reporting off on Room ____. We have Ima Patient, a 73 year old female pt of Dr. Strongbones in here for Degenerative joint disease of the right hip who had a total hip done on the 16th. She is on oxygen at 2L/min, and an established colostomy which needs draining q 3 hours, but she will assist. She is on a low residue diet, which she tolerates well, and is up to the BSC now with PT and 2 person assist. She was very painful today, requiring her PRN pain medications q 2 hours thoughout my shift, and had a valium as well for anxiety after working with PT. She is on the potassium replacement protocol and next lab results will be in at 2000, so be sure to check them out in case you need to give potassium. Possible blood transfusion this evening as well."

Anything else can be seen in my nursing notes or asked to me directly .

Other nurses love my reports..well I also sound like an airline stewardess when I tape..LOL! ('and just in case of a code...the exits are two to the front, two over the wings....."LOL!!!!!!!!!!).

[lmonet82]

Thanks for the tips. I have so much anxiety during report i miss a lot of things because i dont have a clear train of thought