Nurses General Nursing
Published Aug 27, 2002
lisamcrn
79 Posts
Brief backgroung: RN working in LTC for about 5 years.
Current status: RN makes move to Skilled nursing unit in hospital!
RN feeling ok with transition. Supportive staff,
great clinical leader, great nurse manager.
Dilemma: RN feeling incompetant, unorganized...etc.
Why: Getting myself organized for end of shift report,
taping it and having the nurse following me get
the report she needs/deserves!!
Ok...a little dramtic, but I'm in too good of a mood at the moment knowing I will get some great pointers from you wonderful people. My problem is getting myself accustomed to a change of dfferent people everday, getting my responsiblities completed and getting alll this information passed in an organized manner. I know what I need to tell the next shift....but it doens't flow. I've tried different information gathering techniques, a few different forms....that I run out of room on them because I write big or try to condense everything at start of shift so I don't have to return to the kardex. Plus getting labs, new orders and changes passed on.
Now I've done everything I've needed to pass on before with people I've got to know all their family members without a problem and quite well. I can do this....I'm just looking for a way to work this out in a different setting. I have started keeping my copies of new orders, labs etc and just end up with a mess. I've been jotting down on the census sheet my report and pertinent data like expecting labs, ot/pt o2, wt, etc and just end up with that filled before I even start leaving no room for my information gathered for my shift........ugh!!
Any clues?? Thanks so much..........Lisa
(frankly, I don't feel the need to pass all information......that's what the kardex is for.....I keep getting more information at start of report than I need)
CardioTrans, BSN, RN
789 Posts
ok........quick report....... do it by systems.....
start with brief name, age, diagnosis and md name.
Neuro...a&o blah blah
CV....... heart rate & rythym so and so....... bp has been....... IV lines to where and whats running. edema....
Resp; lungs sounds.... any O2.....sats....
GI/GU........ BS, urine output
Then of course in each system what is pending lab wise.... test wise.....anything out of the ordinary
then go over new orders, things to be happening to pt on next shift....
I dont know what kind of unit you work in........ but hope this helps.
Thank you for your response. This is ofcourse my attempt. But after giving verbal report for 5 years I sit down to tape and things go to hell. My mind locks up and I loose all track of logic. Then ofcourse the interruptions start in with people in and out of our breakroom don't help and such.
I think after some reviewing I will just create my own form for quick pertinent notes only and find an empty room to tape where I won't be interrupted.
Thanks.....Lisa
P_RN, ADN, RN
6,011 Posts
Many's the time I took the tape recorder into the restroom (It's a one seater). You can lock the door and no one is walking around you chattering.
I start at the top of the head and work downwards like Cardiotrans does. If you get nervous taping, what if you looked in the mirror and talked to that nurse there?
Dr. Kate, BSN, RN
356 Posts
Lisa, don't be so hard on yourself. You're a good nurse who is an expert in a LTC facility, who is now a good nurse who is now either an advanced beginner or a competent nurse in a skilled nursing facility. It takes 6-12 months to regain your equilibrium after making the kind of career move you made. Already you are utilizing the skills of an expert nurse to solve your problems with report giving and a "paper brain"
You go girl!
Brownms46
1 Article; 2,394 Posts
I use this sheet, and others depending on the area I'm working. Maybe it will give you an idea of how to formulate one for your needs...at least I hope so..) I couldn't download it...but had to just copy it instead. I hope you can understand it..:)
____________________________________________________
Pt Name Age Rm # Dr. DX
Arrival Time: NEW ORDERS *NPO/MN/B/L
HX Procedure/Surg; Heart Cath/PTCA/Stent/CABG/Stress/CT
SURG:
DLYWT * / MED TIMES IVBP IVF I/O
ALL:
TELE:SR ST SB AFIB FL PACING 2L SAT
VS 2000 0000 0400
IPAD / * BS/AC&HS/Q6 1800 2100 0000 0600
CONSENTS yes/no C/O
LABS NEEDED AM LABS NEED TO DO
Results EKG/XR
Problems PAIN/ MED
Assessment: A&Ox ENT Cardiac/CP +/- ENZ#1 / 2 / 3/ +/- RESP M/S
Amb/BR/P GI/N/V/BS LBM * GU/F/V PP +/- Ed SKIN/Drsg CATH SITE/R. Groin/B/S/P
NEED TO DO:
------------------------------------------------------------------------------------____________________________________________________
This didn't come out how it really looks...but hope you get an idea from it..
renerian, BSN, RN
5,693 Posts
I did taped report and at first made a game of it to see how fast I could say the pertient things. Pretty soon I got really good at it. Take some time and don't be so hard on yourself. LTC is a lot different. If you put a hospital RN in LTC don't think she would be comfortable quick. Takes time to adjust to the different venues.
Just wanted to thank you all for your encouragement and advice. I had a great reply written out a few days ago and my 2 year old hit the key and I lost it. Anyway, thanks again, and I did great on my report today!
christianRN
167 Posts
Lisamcrn, I went from working where I gave verbal to working where we tabe about 7 months ago. I ABSOLUTELY HATED it at first. But what everybody has said is exactly right: organization, and don't try to say everything that has ever happened to that pt. It gets so much easier with time. And I try to never listen to myself, because I hate my voice on tape, and it makes me so much more nervous!!!