How to give report?

  1. 0 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?
  2. Visit  ScreamBoxDolly profile page

    About ScreamBoxDolly

    From 'Michigan'; Joined Apr '10; Posts: 14; Likes: 2.

    22 Comments so far...

  3. Visit  caliotter3 profile page
    1
    Don't worry about too much. As you gain experience you will start to weed out the unnecessary automatically. Listen to others give report to see what they include and ask questions of your preceptors. That is the only way to learn how it is done at that facility. Best of luck to you in your new job.
    Momma&RN likes this.
  4. Visit  tuffRN profile page
    3
    We use a DATAS report format: D - Patient's demographic (name, age, sex, where they come from - LTC or home), A - Assessment/allergies (I go through mine sort of head-to-toe: neurological, respiratory, cardiac, GI, mobility, GU, skin, IV access, diet, pain), T - Tests and test/lab results (if they have been an inpatient for a long time, I go with the most recent and/or pertinent tests), A - Alerts (Are they DNR? Confidential patient? Fall risk?), S - Status/discharge planning. Then at the end you can fill in the little details you might have missed during the rest, but I find that with this, most everything gets included.
  5. Visit  EMR*LPN profile page
    1
    The type of report you give depends alot on the assignments. If a nurse has had the same patients for several days, she may not need to know things that happened a few days ago. Ask the oncoming nurse if they are familiar with the pts you have had, and take it from there. Congrats on the new job and good luck.
    VegetasGRL03RN likes this.
  6. Visit  evolvingrn profile page
    0
    Im a new grad to. i have been doing reports since nursing school since i was on a one on one preceptor model...so this is probably where i am most comfortable..... What one preceptor in school had me do that really added to that comfort and i do a mini version of it now is set five to 10 minutes aside if you can to formulate your thoughts and 'practice' . The more i do that the more less daunting it is. you also learn by the questions you get what should just be 'standard' in your report. you will get it , dive in there while you have someone to critique you
  7. Visit  gymmom125 profile page
    0
    Quote from delaRN
    We use a DATAS report format: D - Patient's demographic (name, age, sex, where they come from - LTC or home), A - Assessment/allergies (I go through mine sort of head-to-toe: neurological, respiratory, cardiac, GI, mobility, GU, skin, IV access, diet, pain), T - Tests and test/lab results (if they have been an inpatient for a long time, I go with the most recent and/or pertinent tests), A - Alerts (Are they DNR? Confidential patient? Fall risk?), S - Status/discharge planning. Then at the end you can fill in the little details you might have missed during the rest, but I find that with this, most everything gets included.
    LOL~ now you will all know what a geek i am~ I have been worried about this subject myself, and havent even gotten a job yet. So after reading this post I have made myself a cheat sheat chart to jot which info i will need for report! I sure hope i get a job soon, so i can use it!!!
  8. Visit  mappers profile page
    0
    Quote from delaRN
    We use a DATAS report format: D - Patient's demographic (name, age, sex, where they come from - LTC or home), A - Assessment/allergies (I go through mine sort of head-to-toe: neurological, respiratory, cardiac, GI, mobility, GU, skin, IV access, diet, pain), T - Tests and test/lab results (if they have been an inpatient for a long time, I go with the most recent and/or pertinent tests), A - Alerts (Are they DNR? Confidential patient? Fall risk?), S - Status/discharge planning. Then at the end you can fill in the little details you might have missed during the rest, but I find that with this, most everything gets included.
    I really like this. But where do you put history?
  9. Visit  ScreamBoxDolly profile page
    0
    Thank you guys for your input! I am going to see how that DATAS format works for me tonight. I am doing 3 12's in a row startin' today!
  10. Visit  Meriwhen profile page
    0
    You really will get better as time goes on. When I first started I included every little thing including a lot of unnecessary stuff. I usually gave report to the same two nurses (which one depended on which shift I worked) and they helped me learn how to streamline my report so it's concise but still passes on the important info.
  11. Visit  princessbarbie2717 profile page
    0
    Also a new nurse. (1 yr) We use something very similar to the datas report format. Ours contains the pt history after the admitting diagnosis. We update it once a shift but keep a copy for our use during the shift as a guide. I write down new info or changes in a different color ink, which helps me remember to pass it along to the next nurse, such as significant change in bloodpressure
  12. Visit  mappers profile page
    0
    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.
  13. Visit  piperknitsRN profile page
    0
    Report Sheet for General Medsurg/Tele

    1) Name
    2) Age
    3) Code Status
    4) Allergies
    5) Primary Physician and or Teams involved
    6) Chief Complaint and Diagnosis
    7) *Pertinent* Medical Hx
    8) Isolation for Contact, Droplet, etc.

    Extremely brief, succint narrative of course of day: ("Patient's major issue today was increasing respiratory failure as AEB tachypnea, desats, increased 02 needs. We did a CXR, found her lungs to be wet, gave her 20mg of lasix X1, put her on biPAP and gave her albuterol tx with increased 02 sats, gave.5 ativan IVP for anxiety with good effect. Decreased tachypnea post intervention, but she is still on close resp. watch.")

    *Focused* Review of Systems (Often contains narrative components). (Not all of these will apply to all situations--feel free to add or subtract given your specialty).

    Neuro: Mental status, orientation. BUE grips/strength, BLE plantar/dorsiflexion. Any hemiparesis or gait issues? Need for assistive devices for ambulation or hearing, sight? Any acute mental status deviation from baseline. Time and dosage of last pain meds if given. Restrained? If so, when is the order expiring?

    Cardiac: Temp and source (oral, axillary, core, rectal, etc). Rate, rhythm, arrhythmias, heart sounds, peripheral edema, peripheral pulses, pertinent labs (K, Ca, Mg, Bun/Cr). Repletion of electrolytes if done.

    Respiratory: RR, adventitious sounds, O2 therapy if any, 02 sats on same. Resp. therapy tx's and time of last tx.

    GI/GU: Abd inspection, bowel sounds, NPO or diet status; swallow status; aspiration precautions. Any n/v/d? If so, how treated? Dentures if any. OGT if placed. If tube feed, is it by OG/NGT? Formula, rate, H20 flushes, residuals if any.

    GU: color, appearance, any odor. Foley or other indwelling device. Void amt per hour or shift. If HD patient, HD schedule, last HD date, plans for further HD, whether or not patient is anuric. AVF's, which arm if present.

    Skin: Gen assessment, abnormal findings, dsg changes.

    Psych/social: Family, SW issues.


    Labs values (esp if abnormal).
    --electrolytes, cultures,

    Test Results/Pending Results

    CXRs
    CT scans
    MRIs
    etc,

    Lines:
    Peripheral lines
    Central lines
    Porta caths
    HD catheters


    IV drips--
    type and rate

    Misc:


    Timing of any pertinent med given or due.
    Procedures due/done.

    Plan of care:

    1)Go over shift orders together!

    2) What is/are the *immediate* primary need(s)/intervention(s) for this patient, by priority? (ex: draw PTT for heparin titration @ 0800, preop checklist needs to be completed, pending procedure teaching).

    3) General trajectory of care: What are we hoping to accomplish/which systems need closest monitoring (ex: resp. watch for desats and increased O2 needs, pulmonary toilet, etc, V/Q scan for PE).

    4) Ask: "Any questions?"




    -
    Last edit by piperknitsRN on Jul 17, '10
  14. Visit  LouisVRN profile page
    1
    Quote from mappers
    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?"
    LMoonRN likes this.


Nursing Jobs in every specialty and state. Visit today and find your dream job.

A Big Thank You To Our Sponsors
Top
close
close