What are your most important pieces of information when giving/getting report?

  1. I'm a new grad and have been comparing report techniques from the nurses I work with. Some are to the point, some go on with much information.
    So, can anyone give me the top basic information for report they want to hear/give?
    I work in a Burn and Wound care unit.
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  2. 28 Comments

  3. by   gwenith
    A) is the patient still alive :chuckle

    No seriously - a brief synopsis of care requirements - that is nursing care requirements and then the things you cannot put in the chart. I.e. wound care - what was the patient's reaction during care did they verbalise anything - sometimes what psychological approach seems best.

    Although theoretically we should get all information from the chart we do tend to use verbal as it is quicker. AS I work in ICU I tend to use the old systems approach - neuro, respiratory, cardiovascular, GIT, renal, skin and tissue, psychological and social (visitors) What is said first depends on what was the most important issue of the day i.e. If the patient is neuro - will dicuss neuro assessment ( GCS is so subjective) IF they are long term stable a high point might be taking them for a bath!

    Although a systems approach is good remember that the average attention span is not long so give the most important stuff first!!! Oh and part of our report is checking medication sheets.
  4. by   zambezi
    I usually follow our chart and give a the short version of what I charted. I work in CCU. I start with surgery, gtts...what and how much...then BP/VS...rhythm, ectopy, iabp/artline/bp cuff, anything out of the ordinary, Next neuro, musculoskeletal, pain, respiratory, cv, GI, GU, skin/wounds/CTs, etc. If everything is ok with the system, I just do a "flyby", ie: foley in, doing fine or whatever and move on to something important. If the patient is stable and transferring my report consists of the surgery date/surgery, pt is doing fine, transferring, any important post-op issues. If I am reporting to the same RN as the previous night I just mention any changes. I will mention family if there are issues or they are cumbersome, etc. I vary my report to who I am reporting to and I focus on the major issues, everything else can be read in the chart. 1-5 minutes depending on the complexity of the patient. I also point out anything that the day RN needs to mention to the doctor or changes/errors on the med sheet and allergies.
    Last edit by zambezi on Aug 9, '03
  5. by   ernurse728
    Code Status!
  6. by   gwenith
    This is going ot be an interesting thread!!

    Want to bet we each end up with a different list depending on where we work?
  7. by   redwinggirlie
    I sure hope so. Thanks for the input thus far. More! More!
  8. by   Marie_LPN, RN
    My ears and my full undivided attention.

    One out of two isn't bad though.......
  9. by   Tink RN
    #1 - Name, age, gender, code status
    #2 - Diagnosis
    #3 - Admitting physician
    #4 - Medical History
    #5 - Labs / x-rays / procedures done
    #6 - Meds given (and response)
    #7 - Vital signs, mental status

    ER nurse ... is it showing? :spin:
  10. by   Sarah, RNBScN
    #1 - Name, age, gender, code status
    #2 - Diagnosis
    #3 - Admitting physician
    #4 - Medical History
    #5 - Labs / x-rays / procedures done
    #6 - Meds given (and response)
    #7 - Vital signs, mental status
    -----------------------------------------

    Ditto:
  11. by   KaroSnowQueen
    This is what I GIVE in my report. Very seldom get this much back, though. I give it in a brief format, HATE those dragged out, "Well, the pt did this and I did that, and her family said this and it was raining outside and the birds were singing...." type of reports.
    A&O x?
    heart rate, any irreg, on monitor or not
    resp, o2, lung sounds
    iv site, fluids, drips, any pending labs r/t these
    abdomen, bm
    foley?
    edema? any pulses NON palpable?
    accuchecks? hx of very high or low sugars this admit?
    skin? dressings?
    family support? or not? or hovering, demanding?
    abnormal labs, pending, protocols started r/t labs (K+)
    post op day X? NPO for WHAT being done today? Consent signed?
  12. by   PhePhe
    Bare Minimum:
    1. Name, operation or major condition
    2. Wound/dressing change status
    3. Tests or major things that happened or to happen within 3 days
    4. Pain status
    5. Things that need to be checked: Acuchecks, foley, IV, Peg tube

    I notice people hae gotten away from giving IV and TF credits, and cont. suction and Foley amounts. I want to know the IV credits because it might effect the order in which I go round to check the patients.
  13. by   Monica RN,BSN
    In LTC the residents are pretty well known and report often consists of "Mr. Smith is fine, Mr Jones had a good day, Mrs. smith has been uncooperative today, ect ect....."

    But very diff in a hospital, acute care and ER all of whic I have been,

    I prefer more of "Rm xx, xx year old m or f, mental status, diag, any prn meds given, ect...

    ANYTHING THAT WAS NOT COMPLETED FROM PREVIOUS SHIFT, so it doesn't fall through the cracks, like orders that were not gotten too, phone calls that are expected to be returned (nice to know what the call will be about) any calls that are intended to be made, but not gotten too.. stuff like that really helps
  14. by   rollingstone
    -Chief complaint
    -Diagnosis
    -What was done to make chief complaint better.
    -Meds given or held, IV's, allergies.
    -Pertinent labs and history.
    -VS, assessment findings.
    -Mental status; code status.
    -Family members present.

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