whats important in report?

  1. just asking other nurses what they think is improtant information to pass on in report...

    i like to know:
    diagnosis
    orientation
    any events thru the last shift
    prn med times
    accuchecks.
    anything out of the norm (abnormal labs)
    location and description of wounds--wound care


    sometimes report takes long because the nurse giving it tells every little detail.
    i dont write down all that much.
    i dont write down vitals unless they are abnormal...same with labs. i dont care how many rbc a patient has unless its dealing with h and h
    they dont have to tell me how old the patient is or who his doctor is,....thats all written on our care papers. so is past medical history.


    is there a general protocol for report?
    am i missing the boat here?
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  2. 19 Comments

  3. by   misti_z
    I agree with you. We have PCAR (patient care activity reports) though that are printed out at the beginning of shift that has age, MD, admitting Dx. So you don't need to tell me that. It doesn't have past med Hx so I like to hear it. Including all that you said I like to hear parameters: call MD if ....., Give clonidine if BP >.....and so on, also any lines (permacath, tessio) or HD grafts.

    I'm unaware of a protol, but one would be time saving. Sounds like you would give a fine report........Your on the boat!!!
  4. by   hoolahan
    Agree with everyone. One nurse I used to work with called that kind of report all meat and no gravy! I liked that one.

    One more thing I like to know as an ICU nurse is a bit about the family. What have they been told about the pt's condition? Do they know the path report is + cancer? Are they supportive? Are they ready to discuss DNR if appropo. Just a little psychsocial, what is the pt's biggest fears, etc... That's the stuff many people pass on but don't document. In other words, prepare me if the family is nuts!
  5. by   frustratedRN
    the family is always important.
    i always ask about them when im told that a patients condition is grave. i also ask if the patient is aware of their condition.
    i report off to one nurse that writes down everything i say. when she reports off she tells me every little thing. i know before i even go in that ill be there for about 45 minutes.
    report shouldnt take that long. it puts me behind right at the begining.
  6. by   hoolahan
    frustrated I have had many reports like that, where I wanted to grab a pillow and start dozing it was so montonous and boring!

    What you have to do is say, "Yes, I remember, I had these pt's yesterday, just tell me the highlights of what happened today." If they keep rambling, cut her off, and ask the questions you need to know, keep firing questions, get what you want, them flip the kardex to the next page and do the same. After a few reports like this, she will (hopefully) get it. OR, more to the point, you could tell her privately that you would like if she could shorten her report a bit, because you have to start your assessments promptly or you feel you are behind all day.
  7. by   tiger
    we have one nurse who goes on and on in report. she'll say "i got the pt. up to the bathroom and the pt. said she didn't feel well so i took her blood pressure which was 120 over 80 and i helped her back to bed. then i asked her if she was having pain and she said yes but not much. so then she said she felt ok and asked me for a blanket. i got her the blanket and covered her and left the room. she rang again but said it was an accident." talk about a waste of time. she charts the same kind of stuff. he said she said alot.
  8. by   CEN35
    ER to floor...........

    Name
    age
    allergies
    Hx
    events up to situation...
    Pt baseline
    relevent meds to situation
    relevent labs to situation + abnormal lab values
    Radiology issues if relevent
    EKG
    IV's -drips.sq start or ours
    last set of VS
    then ask any questions?



    me

    I will not read thw whole chart they can read I assume?

    me
  9. by   Cafe
    I work in an IMCU unit so:
    PMH unless I had the patient the day before
    VS if unstable
    gtts- rates and next labs for those if needed
    orientation
    dressing changes if needed- be it Picc or wound
    sxn needed previous shift
    any tubes in any orifices or elsewhere
    Code Status
    family issues and needs
    lines pulled- time, off bedrest when, site assess, lab times
    Pertinent stuff for Vents, bypass, or recent ABGs
    Otherwise I can gather from flow sheets and chart.
    I have found certain nurses want every single detail and some that don't even want to listen to tape and for you to give them a verbal highlight.
    I am probably more thorough when they transfer to another unit, more stable floor and I try to listen to what they want.
    I still keep trying to adjust and understand the ER's report
    Explain to me CEN35. I can't tell you how many times we have gotten patients that come in with chest pain and the nitro gtt is set up at 5 mcg and they hit the floor and still having chest pain and pressure is up and they haven't turned the gtt up and or in CHF and haven't listened to their lungs Please explain if I am missing something here. I have backed off from needing a thorough report and hit me with the highlights but geez!!!
  10. by   CEN35
    Sorry Cafe...........

    If they still ahve chest pain they either have an SBP of about 110 and the NTG drip is maxed out, and/or they are also on heparin and either Riapro or Integrelin, and the trip over is temporary until the cardiologist is present to cath him. Also, they have had enough Lopressor to keep their heart rate at about 60, and they are on O2, what else is there? Myabe their EKG looks perfectly normal also? Maybe it's GI!!!! LOL! Sounds like lame transfers, from lame staff in your er........of course thats just my opinion.

    me
    Last edit by CEN35 on Aug 31, '01
  11. by   tonchitoRN
    I used to work on a busy Telemetry unit where it was not uncommon to see 8-10 patients on an 8 hour shift. I used to laugh when I gave report to an ICU/CCU floater. They wanted every detail including PMHx and ALL labs. I used to tell them that info. is in the chart. When one nurse got indignant I explained "look you will be lucky if you spend more than 15 minutes with that patient. It is not important if that patient had a tonsilectomy at 6 yo. What is important is XYZ." This same nurse complained if when you gave the dx of MI you did not say where the MI was. I thought maybe she had a point so I asked her "on Telemetry is the care different for a lateral wall MI or an inferior wall MI?" She had no answer and never asked that question again.
  12. by   MollyJ
    Tonchito,
    Alot of acute CCU nurses will want the location of the MI because it warns you of possible complications (ie MI area specific blocks) and may dictate treatments (RV MI). HOWEVER alot of these problems become less likely in the post-acute phase (which is why you don't care about them).

    I have been an ICU nurse that floated to a lesser acuity unit and it is hard to "turn down" your need for information. Knowing those kind of details in the ICU can help you anticipate and respond to complications. Knowing them on a more general unit has a lower "yield" of usefulness and can cause sensory overload. Most ICU nurses feel pretty out of control on lower acuity units because they CANNOT amass the type of detail they often can in the ICU.

    I agree with the "just the facts, ma'am" lists that have been posted here, but I also like to know about family coping issues, DNR issues but not in excruciating detail.
  13. by   Cafe
    CEN35--- Thanks. We are (or there is a comittee) working with the ER on some of those issues- like Nitro Gtts. I figure other problems can be worked out and sometimes escalate due to the fact that nowadays our unit is generally full, or we triage out and are near capacity on the next shift or within two shifts, which at some point delays things in the ER and causes backup down there. The other is diversions from our UW Hospital. They have serious staff problems so have to divert. They also haven't settled their contract and the hospital won't negotiate anymore and has just put into effect their offer in hopes of breaking their union. Doesn't solve any of the problems though and they still can't retain staff. Causes alot of open beds not utilized and our hospital and another are full due to their overflow!! Can get kind of tense at times!!
  14. by   night owl
    I only like the highlights because giving report on 30 pts can be a bit lengthy. Then again, there are nights when everyone slept, a very uneventful night and feel that I should have SOMETHING to report. I should be thankful for those nights which are few and far between...

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whats important in report?