Research patient or see patient first? - page 3
Hello, A novice RN here asking mostly for professional opinions. I've noticed that older and more experienced nurses will get report in the morning, take down notes from the night shift on... Read More
Jul 29When I still worked the floor after report, I went through each of my patients and read through the nursing notes, labs, last few orders on every patient and made any notes I needed to make before I saw a single patient.
You would be shocked at the information you never get in report. Going through the chart first allowed me to clear up anything with the patient when I first went into the room.
If you are well versed in how the computer system works, never took me more than 15 or so minutes total because I am looking for zebras or discrepancies..I don't need to write down information I already received in report.
Jul 29I like to at least glance through labs and most recent reports. 1) I can fill in any gaps in report (Brain MRI was positive, etc.), and 2) I know what questions I want to ask (Was that K or 2.9 replaced? Or the SBP of 180 addressed?). Then I can see the patient and dig deeper into the chart. Some of the things that I want to make sure have been addressed aren't going to show up on the patient yet, but I want to get to them before they do.
Jul 29I'm still a new nurse but I always come in early(like 20 to 30 mins before the start of shift) to browse the chart before laying eyes on the patient. My floor only allows us to get report 6 minutes before the start of shift so I usually write down which patient has which meds, labs, or reason for the surgery if I'm not familiar with the patient. I work on a surgical floor so things tend to move quickly.
I would say do what works best for you but I have noticed it all depends on who you are getting report from also. It can make all the difference
Jul 30I clock in at 7:53 and have 7 minutes to write down the basic info on my patients (name, age/DOB, diagnosis, pertinent PMH, when the best med is due, etc). After I get report I go directly to my patients to take their vitals, check their drips, and do an assessment. When my assessments are done, before night meds, I take a better look at their EMR. Overnight when I have more time, I look at their chart in more depth, reading all the reports and what not.
Jul 30I'm doing a full assessment first every time. I've read charts that make the patient sound like they're knocking on deaths door, and they look phenomenal, and seen some people who look terrible, but the chart doesn't say much to alarm you. The assessment, focused or head to toe, is going to give you the most valuable information. I too work nights, so doing an assessment first also allows me to call the doctor early if I see a problem (in theory...usually when the stuff hits the fan on night shift, it happens at late- as- ever- o'clock)