How to give report?

Nurses General Nursing

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I am a GN and now am orienting on midnights (which surprisingly I like lol since I have never worked midnights). I guess I am nervous about a lot of things, but I try not to show it. One area I feel like I am lacking in is report. Usually my preceptors do it, but I try to say comments in between report (so it looks like I am trying). I just get so nervous and frustrated inside because I feel so incompetent. I am still trying to remember what the nurse before us said about the whole patient (which I do write things down), but sometimes I feel like more is said than needed. I guess I want to be more like "here are the facts that are important" and I don't want say stuff that isn't important. So any suggestions / stories of starting out please? :nurse:

Specializes in Med/Surg.
Can someone explain (give an example) of how you use SBAR for giving report to oncoming shift? Using it to call a doctor to report a change, critical lab, ask for something I get. Using it for report feels to me like putting a square peg in a round hole.

Here is an example of how I would do an SBAR format for a typical post op patient

" S - This is John Doe he is a 50 year old male admitted for a ventral hernia repair with mesh with Dr. Jones yesterday, Dr. Smith is his attending, and Dr. Heart is his cardiologist. He is a full code with NKDA

B - He has a history of CAD with Stent placement in 2009, diabetes and GERD. His only other surgical history is a T&A as a child.

A - His vitals have been stable throughout my shift BPs 110s/60s with a pulse rate in the 70-80s. His resps are even and unlabored and he sats in the high nineties on room air. He has a midline which is CDI with original surgical dressing. He was able to ambulate in the halls independently and has BRP with good urine output. I heplocked his IV per orders as he is now tolerating his 1800 ADA diet. His blood glucose last night was 110 with no insulin coverage.

R - I would recommend switching his pain medication from morphine to the lortab as he is now tolerating his diet and his plan is to go home with his wife later today. He last rated his pain 3/10 and denied need for any pain medication, so his last dose of morphine was at midnight. I do not anticipate any barriers to his discharge and I have completed his post-op teaching.

Are there any questions I can answer for you?"

Specializes in Med/Surg/Tele/Onc.

Thanks LouisVRN

Specializes in Med/Surg.
Thanks LouisVRN

Np, its how we give report every morning. I try not to give too many details as we give bedside report and give the patient a chance to ask questions/clarify as well.

It works pretty well once you get used to it. I have issues with nurses who give too long of a report. I don't need to know how long the patient walked for, how many cc's of urine he had, the number of times you medicated him, what he had for dinner (you should have documented that). I want to know what I need to know to keep the patient safe and do my job not how well or inadequately you did yours.

Specializes in Critical Care, Surgical ICU.

Thank you soo much everyone, I too am a new grad and have been very nervous about giving report. I gave it for the first time on Thursday and the girl said I could have fooled her. (I think she was just being nice)

Specializes in pulm/cardiology pcu, surgical onc.

We use SBARR, the last R for readback on the rare occasion we take an order from a physician. We also use in bedside shift report, trying to keep it to the brief and to the point.

Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

I'm attaching a helpful SBAR document. Enjoy! :)

sbar_draft.pdf

Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.

SBAR is great for one dimensional issues, but for shift to shift report? What happened to the nursing process?

Specializes in med surg nursing.

Please...make sure you report alert and oriented, confused etc. Also very helpful is activity and how the patient potties. I know it sounds trivial, but if I have been off the past three days, it's great to know if they are incontinent, bedpan, bsc, or brp.

Are they independent or are they a fall risk.

Just please don't report "no changes, patient is the same". We have midnight nurses who report that. That is no help to me if I have never taken care of the patient before.

Specializes in Emergency.

When I hand off a pt to a nurse that hasn't had the pt before, my report is usually similar to this.

1) Name, age, sex, admitting date, MD, code status.

2) Admitting diagnosis, followed by pertinent history. I'll usually give a brief narrative of what's happened in the last few days (blood transfusions, other services following, imaging studies, etc.). I follow that up with the important things that happened during my shift (like my pt this morning whose K was 2.5).

3) IV access, IVF, PCA, & drains/other tubes

4) room air vs. oxygen, VS frequency and how they've been trending over night, daily weight or not, how they move, how they go to the bathroom, diet orders & how they're eating, any skin issues, accu checks if applicapable

5) social issues and the plan for the rest of the stay/discharge

We print a kardex every shift and I use that to receive report, make notes about the pt during the shift and then to give report to the next shift. Works great as it keeps everything on one sheet and I've worked out a system so I know by where things are written on the page what they mean (bottom left is my assessment, upper right is what I got in report, bottom right is new orders, middle of right side is abnormal results from my shift).

I start with the room number, pt name, doctor(s), diagnosis and pertinent history. From there, it's info that we fill in on the kardex. VS frequency, if they are a daily weight or chemstrip, amount of o2, IV access (and any fluids running), if they work with PT, if they are incontinent or have foleys and what their activity level is.

Once all that stuff is covered, I go over anything that I feel needs passed on from the report I got. Some things we'll pass on for several days, like a blood transfusion. Other things we may or may not pass on at all, like tests that came back with normal results. I also include abnormal procedure results as well as abnormal labs. Then I'll mention new orders/happenings from my shift and anything that needs clarified or addressed.

I generally do not include info from my physical assessment unless it is something way out of whack that they really need to pay attention to or address (no/low urine output for example). Our assessments are documented in the computer and if they want to compare, they can look that information up.

I am a new nurse working in Cape May, can't begin to tell you how much I appreciated the gift my boss gave me of telling me about this web site. The information about DATAS - got me organized and for the first time I felt like I had a real handle on it, and the reception of my still in-experienced but comprehesive informational report was received better than I expected - more importantly - I didn't miss anything important The kind words about patience were heart felt, with a long way to go to get better - I feel like i'm not so alone anymore.

Any comments on how to deal with the dynamics of changing information that comes in as your giving report on a patient that the doctor is writing new and changing orders on as the shift is changing. I'm willing to stay to get it done, just trying to figure out what to do so as not to affend any one? They step right up but isn't my responsibility until everything is calm?

Have a great day, and thanks

See you soon, this is my new favorite web site - check the time out have a great day

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