What Do You Want To Hear When Receiving Report? - page 3
When signing off duty and giving report about my assignment to oncoming staff, I usually advise of what I did for the patient during my shift (ie...Meds, dressing's, any treatments or pre-op prep),... Read More
Dec 22, '02My report usually goes like this:
VS (any abnormals with treatment rendered during my shift)
GI (tubefeeds, residuals, if NPO after a certain time)
IV Sites (central lines, if any are clotted, arterial lines)
IV Fluids (KCL, Mg, Antibiotics given or need to be given)
Plan of care (transfer to step down when bed avail, Social Service consult for placement, family plan to make DNR in am, etc...)
Dr. on call, or Fellow or Resident covering.
Tests pt. went for and outcome (i.e. CT Brain = no bleed, etc.)
Hope this helps. I am probably forgetting something but that is my basic report.
Dec 22, '02Looking for QUALITY vs. quantity when receiving report. Plan of care is #1. Also, very important to note type/rate of IV fluids -- as well as approximate # of cc's left in bag -- better yet -- when you are charting I/Os at shift end, if there is less than one-two hours of IV fluids left -- hang a new bag for the next shift.
Dec 22, '02Great thread...very interesting.
I always find out from the oncoming staff if they know the patients. If so, then they don't need all the history, no point in going all thru it again. Any new admissions since their shift, I give a brief history on. Then I just give changes since they last saw the patient and upcoiming orders.
I work all night shifts, so I find that is often the only time when the charts can be thoroughly reviewed, and I can check any thing that has been overlooked and pass that on.
I work float pool in a big place so move around a lot. Each unit has a computer printout that each shift updates and prints for the oncoming shift. It has diagnosis, brief past history, IV's, drains etc, IDC's, diet, mobility, freq of vitals and a box for notes. Sure streamlines what you have to write down. This folds into my pocket, I can add notes to it, then I handover from it in the morning.
Dec 22, '02Originally posted by NancyRN
There was another thread about "bullying during report" that was interesting. I think that some of the questions asked are more to show off than an actual need for information.
My favorite thing is when a nurse is tossing terms at me and I stop her and say "what's that mean?" and she doesn't really know.
Let me give my report please, don't interrupt, and then you can ask your questions. I hate when someone asks "what kind IV is he on?" "Well, if you shut up long enough I WAS GOING TO TELL YOU!" hehehe
Dec 22, '02I'm not a nurse, but work closely with "them." :-)
Bullying at report? If a RN used a meeting as a plank to begin bullying? There is no excuse for this behavior.
Just know that if I was at report and assessed open-bullying, i would start barking about it right then & there. You see, a bully will one day try it with YOU. The bully is actually a good luck sign because it brings together those that actually take part in the bully's destruction :-)
Dec 22, '02originally posted by susanmary
if there is less than one-two hours of iv fluids left -- hang a new bag for the next shift.
this is one of my all time pet peeves!!!!
Dec 22, '02Originally posted by 3rdShiftGuy
I work with a nurse exactly like that. She always asks a million questions that you can't answer. "What was his Potasium Level 16 days ago?".
Dec 23, '02Originally posted by Sleepyeyes
I like our report system. We have the halls divided and a tape recorder dedicated to each section. You can go give report whenever you have a few minutes, you can talk as fast as you want, and the oncoming shift can just stop the tape and write as much or as little as they want.
Dec 23, '02Originally posted by susanmary
Also, very important to note type/rate of IV fluids -- as well as approximate # of cc's left in bag
I will report this information if the MD has ordered something like "2 liters then heplock" or something of exact like this. Otherwise, I record and add up my shift I & O's that can be reviewed later.
Sounds like "important report information" is subjective, and no one way of reporting is the "right" way?
Dec 23, '02Originally posted by aus nurse
Each unit has a computer printout that each shift updates and prints for the oncoming shift. It has diagnosis, brief past history, IV's, drains etc, IDC's, diet, mobility, freq of vitals and a box for notes. Sure streamlines what you have to write down. This folds into my pocket, I can add notes to it, then I handover from it in the morning.
Dec 23, '02I can say this is why I moved down to the OR from the floor. Report from the floor from the offgoing shift took and hour and by the time we got on the floor we were so backed up from listening to their trival crap of thier day of events which very little had to do with patient care. We worked second shift and our report to us almost at times took and hour which is rediculous and we were running out of the report room to get our day going and 90% of the time completing what first shift didnt do. You all know the storys too many chiefs not enough indians.
By the time we got our shift off and running we were behind and busted every hump possible to catch up and stay ahead if we could. At the end of the night our report lasted a total of 30 minutes and it was filled with everything done during both shifts and what is to be done during 3rd shift and it was filled out on the patient census and with all needed info on the sheets and a overview done during report.If there was a change in anything other than (hey they're in the hospital for a reason) it was on the sheets. VS, labs due, abnormals and drsg changes where on the sheet, also if there was a consent form to be done and a prep.
Now in surgery I love it. When I drop the patient off in post op I giveALLERGIESn or off o2,cardiac status,pulse points and marked.Surgery done, Surgeon, Anasthesia type, tolleration, VS, drsg and where and if any change and type marked, if family is here and reports to family given and if we have attached something to the patient that needs to be monitored and how it is to be monitored, and what room I will be in and what room the Dr will be in if complications occur. They seem to like what info I give its too the point and doesnt take a month to give it.
Dec 23, '02Just the essentials please...I don't want report for an hour on 3 kids...all that are feeders and growers! A critical vent or chronic kid, sure lay it on me, but forget all the other stuff. I have had nurses go on about what came out of a kids nose and not tell me, oh yeah, he grew out gram neg rods by the way from every body fluid we sent. Good grief! And I hate those people that expect you to spew out the whole HandP when you have only had the kid for 4 hours! And really, after the kid has been here for months, who cares how much bowel they lost...just tell me if they still have their ileocecal valve and whether they dump or not!