Charge RN Shift Summary/Report?

Nurses General Nursing

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Hi All,

I work as a Charge RN on a med-surg unit and I'm looking to see what others do for their shift reports/summaries. Currently, we have a template which is then handwritten for each patient that includes Name, Age, Sex, MD, Allergies, PMHx/PSHx, Code Status, Isolation, CMO (comfort care), DPOA status, Recent tests/procedures, IV access/fluids, abx/steroids, diet, activity, abnormal labs, Anticoagulation, PCA/PCEA/Pain/Anxiety, Dialysis access/schedule/fluid removed, etc. The Charge RN gets updates from the other RNs and writes them per shift, and then uses this for daily rounds to provide a snapshot of the previous shifts, and identify any barriers to discharge etc.

I'm looking to see what everyone else uses, and perhaps for a copy of the report sheet that ya'll have as well as any ideas. Any info is appreciated!

Specializes in NICU, ICU, PICU, Academia.

Wow! That's a LOT of info. We do a basic rundown of the patients (15 bed PICU) identifying diagnosis, vented kids, isolation, critical drips and who is likely to be extubated/ transferred out on the following shift. We mention pertinent social stuff (we get kids who are under CPS status) and outliers (language barriers etc) Takes about 5 minutes max.

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

I worked as a house supervisor for the better part of four years and would be peeved if I was forced to provide such an overkill report.

The unit secretary prints out a template with the names, room numbers and genders of every patient on the unit, which is handed to the supervisors. We then discuss any significant changes, family dynamics, dialysis patients, IV antibiotic therapies, pending surgeries, and infection control issues.

That sounds like WAY too much info, for a supervisor. We print a census sheet, and only go over in depth pt's that are critical. The others are looked at for possible d/c's, primary fix, and response. Since it's a tele unit, we also look at who is stable and can move out , and any drips or arrhythmia a. Shorten that up! You could spend hours on that!

Thanks everyone for your input! I failed to mention previously that we are a small, 10 bed unit that's focus is on med-surg, particularly women's health, dialysis, diabetes, and DKA. We have 2 nurses and 1 LNA on at any given time. Anything to save time, yet provide a clear snapshot for the oncoming day nurse who has to do report with social work, case management, dietary, and PT/OT.

Specializes in ER.

Our Charge report typically consists of "Any inpatient holds? Anybody going down the tubes fast?" "Are there 5 squads currently inbound? No? Really?! And the lobby is almost empty!" "See ya in the morning."

Although charge report was considerably more involved when I worked inpatient. To the point of being cumbersome & I didn't see the point of knowing all the information that got passed back and forth.

Charge to charge, or charge to supervisor. Supervisor was short and sweet, charge a bit more involved, as there are times when charge is the only pair of " free" hands. I worked on a 26 bed tele unit, ratio 5 or 6 to 1, charge did not take pts. Also 2 CNA's. Then the powers that be decided charge should take an equal assignment. Only recently did they set up tele techs, but ultimately that bank of monitors was one more thing you needed to watch, while giving pt care. Often had to transport unstable pts ourselves, which makes sense, but nobody's really watching your pts, too busy with their own. We had to transport pts , in beds, to the Catholic lab. Sometimes they'd call and ask us to come get, too. We had post PCI, critical medical pts, detox, drops, stable vents. It was a nightmare; glad I'm out of it!

I'm specifically looking at charge to charge report... I work nights and trying to give report to days, who then in turn has to report off to case management, social work, and other disciplines.

Usually the report sheet from epix is good to go...it contains most of that info

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