Most report sheets and change of shift articles I've read only address acute care. I'm a LTC DON looking to streamline our report process. What elements do you include in change of shift report? What do you AVOID including? Any report sheets you can share? Thanks for the help!!!
Oct 3, '12
We are a mixed LTC/STR- so on the rehab's we give admit dx, general info (diet/code/mental status) and any current issues. For the long term patients we only report that 1. they are stable, no issues or 2. mention any changes/falls/new meds/current issues, plus give recent cbg's etc. I just left the hospital environment- I couldn't even fathom giving that extensive report on every patient in LTC! That would be quite daunting. I don't have a copy of our report sheet, but below is basically what it looks like, just add lines where appropriate.
Smith, J (MD name/code status)-
Brown, B (MD name/code status)-
Oct 4, '12
in LTC: if patients take meds whole or crushed, dx, treatments, new orders, basic mood of the day, labs/results
Oct 6, '12
I'm trying to get my nurses to get in the habit of reporting most recent blood sugar for diabetics, last BM and last narcotic dose if applicable. These particular pieces of info help the oncoming shift tremendously and are key to avoiding some sentinel events. Add that to isitpossible's response and I think you have it covered.
Oct 7, '12
At my facility we do not have a standard "report sheet," we simply use our census sheet to give report. The previous post does highlight some very important points that should be covered in report, but both the oncoming and outgoing nurse should know to report these things, they shouldn't have to be on a sheet for each resident...
When I oriented at my facility I was taught to mention those points (where applicable) during report.
Oct 7, '12
We too just use the census sheet. We report acute things like abx/uti's, out of the ordinary behaviors, any PRN's that were given and why. Any empty beds, anyone sent to the hospital. Falls and other A/I's also on report for three days, ex: s/p fall day 1/3 no apparent injuries. Or day 2/3 skin tear; steri strips intact to RFA. Stuff like that. WE might also mention informally that so and so is sliding down in their chair and needs to be seen by PT or that someone didn't eat dinner, but that isn't usually on the report formally, just a sort of keep your eye on...
If a nurse was just on the floor yesterday the report is less detailed than if a new nurse to the floor comes on. The way they take their meds would be on the MAR, but we usually include it in report as a courtesy.
Any res 'on report' gets charted on and put into the REPORT BOOK, which goes to morning meeting with the RN Supe.
Oct 9, '12
In addition to what others have mentioned, we mention whether the resident is skilled, on hospice care, or on 15-minute checks. We also mention if they haven't had a BM in 3 days, what we did about it and whether there were any results. It's always possible the incoming nurse will be a float, so we report accordingly. The floor nurses pass along a census sheet which has a column for each shift - the way I use mine, the notes on it are exactly what I pass on in report. This is different from the unit report, which is just for acute events that the supervisor needs to be informed of.
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