What Do You Want To Hear When Receiving Report?

[rebelwaclause]

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), what was abnormal during my shift (including what physician was contacted and what I did as ordered by that MD), and other pertinent information that would be useful to oncoming staff to know.

I've had nurses go on and on about vital signs from 3 days ago that is not relevant at that point. I've heard long drawn out history about labs from a transfusion days ago (no side effects). I've had a nurse get mad at me for not knowing off the top of my head whether or not patient teaching regarding home abx had been taught to the wife. (The patient was a&ox3. Absolutely no learning barriers. I did advise that the patient did an EXCELLENT return demonstration!)

I find every nurse to be a little different in the information they need to feel comfortably informed. Some want the bare necessities, others want a full head-to-toe assessment.

My question is, what type of report do you need to feel informed? Does the shift you work make a difference in the report you want to hear? What information do you think is unimportant?

Thanks for your feedback.

[neuroRN, RN]

I like to know what occured on the shift I am taking over for, abnormal labs or vitals, PRN's given, etc. I also like to know when the pt first came in, (ie: this pt was admitted 12/22 s/p crani) and what the plan is for the pt (ie: once stabilized the pt should go to Mediplex for rehab). ONe big gripe I have is when we have a pt who has been on our floor for a while and I have never had them and I hear "I am sure you have had them so I will just give you updates". And also, I want to know valid history of the patient, if the pt is here for a spinal fusion but is a quad from 1 year ago, I kind of need to know, however sometimes it is neglected to be mentioned.

[mario_ragucci]

Originally posted by joyflnoyz

"Contact isolation D/T MRSA/blood"

What is D/T? I know what R/T is. Also, what exactly does contact isolation mean? No one is allowed in the room unless totally gowned and gloved and masked and footied and cap? Is there a nursing diagnosis to do with mrsa? See, I heard of isolation, and then there are precautions. I will look it up. Thank you for sparking my interest and it is good to know (no one cares)

[SKM-NURSIEPOOH, BSN, RN]

originally posted by mario_ragucci

what is d/t? i know what r/t is. also, what exactly does contact isolation mean? no one is allowed in the room unless totally gowned and gloved and masked and footied and cap? is there a nursing diagnosis to do with mrsa? see, i heard of isolation, and then there are precautions. i will look it up. thank you for sparking my interest and it is good to know (no one cares)

d/t means: due to.

contact isolation just means that staff/visitors have to gown-up & wear gloves to preventing any physical contact with a patient with say something easily transferable like scabies, herpes, lice, mrsa, etc. masks & eye protection isn't necessary but in some cases, caps & footies are. hope this helps .

cheers - moe.

[rebelwaclause, ASN, RN]

Yes...Isolation precautions is VERY important information to know!

[boggle, ASN, RN]

I really appreciate the ideas and guidelines for report that you have shared here.

I am finding it hard to keep organized when I report off. The shifts have been more and more busy, to the point where my brain is spinning by the time I sit down to give report. (maybe I should just stay standing;) )

I float, and am part time, and almost never have a patient two days in a row. I feel behind from the minute I arrive and never catch up.

An organized report with the PERTINENT details from the off-going nurse is SO helpful. I strive to give the same quality report when I go off, but.........

oh, for a few minutes to collect my thoughts...........

[NotReady4PrimeTime, RN]

I work peds ICU. We have a set format for report that follows a system review model. 60% of our pts are post-CV surgery and are usually only with us a few days, so a brief PMHx is included at the beginning... age, wt., date and reason for admission (ie defect(s) and procedures performed) and any contributing info, such as ex-prem, Down's and such. Then we go head to toe. Any meds given for problems related to each system are included in that section of the report. Significant events such as hypotensive episodes and volumes for fluid resus, dysrhythmias and their tx, bleeding, etc are included. At the end both nurses review only new orders from the shift just ending and ensure that they are double signed on the Kardex. It rarely takes more than 10-15 minutes to give a complete report. I tend to be one who gives more information rather than less; I read all the consults and diagnostic reports and like to pass on pertinent info gleaned from them.