Giving Report

[BoyNamedSue]

Hey everyone, my first post. I recently started working at a LTC facility as my first position out of nursing school. I'm having trouble giving report. I got ripped by another RN for not saying how a new admit ambulates, and this really made want to get better. My questions, what should be included in a report, and any tips on getting better? I've been organizing my patient sheet with vital signs and assessment data; however, I seem to forget info such as if a patient has an appointment coming up, how much she ate at supper, or how he transfers. Any help is appreciated - right now I feel swamped with paperwork, patients, and charting.

[BahoRN]

I'm wondering if Baho and Gabby work the same kind of LTC that I do. When you have 20-50 patients you can't give a detailed report on each one. You also don't need a detailed report/assessment sheet on each person. Each facility I've worked has a report sheet that has a list of all the residents and normally has very basic info like if they are diabetic, or on hospice, if they are on thickened liquids, how they take their pills, etc. When I take report I write my report on this sheet in red, and then through my shift I write vitals, PRNs, and anything I need to pass on in black.

I've never worked in LTC so i'm not aware of acceptable repotting practices in these types of facilities. Working in acute care, so many changes take place during the shift, your nursing 'brain', which is your paper on each patient, is very important. It helps with tracking changes, shift report, end of shift charting, and follow up for the next day when you have that patient again.

[chrisrn24]

Yeah LTC is way different.

I will give a detailed report on new residents. "90 y.o. male admitted with CHF exacerbation, here for PT/OT. Hx of blah blah blah. Transfers with assist of 1 and walker. Independent bed mobility. Continent of bowel and bladder. Takes meds whole with water. Low sodium diet with regular fluids. Pleasant tonight. No behaviors."

Otherwise it's "residents a b c d are fine, e is on Keflex for cellulitis. Temp 99.1. F g and h are fine. I had behaviors today of blah blah blah." And so forth.

With upwards of 30 residents...as Sweet Brown says "ain't nobody got time for that!"

[systoly]

report is an important part of (continuity of) patient care

it involves at least 2 staff members and so the responsibility

to ensure a successful report lies with at least 2 staff members

it is yet another skill that improves with experience (hopefully :) )

that fact that you care and want to get better at it makes you

golden in my book

rather than ripping you, a seasoned nurse could take the opportunity

for teaching such as explaining why something you omitted is of

importance

i like to carry a notepad with me all shift and organize my report sheet

at the end of the shift, if i'm not quite ready for report when the oncoming

arrives, i'll tell them i need a minute and to feel free to look

at the new admit notes, labs or whatever is new

don't sweat it too much, you'll find your own system and you'll get good at it

[pinkiepieRN]

If they're long-term residents, I report changes such as falls, fluctuation in mental status, agitation and if any meds were held (wonky BP, resident refused, etc.) ABT is a big thing to pass on in report, because they automatically get a nursing note Q shift. Otherwise, new orders and return from LOA or appointment (including dialysis) are my major focuses. Definitely pass on information about pain, anxiety, itching or anything else that might require a PRN, when they last got it, and whether it was effective or not. If they're on finger-sticks, make sure you know their last result and how often they get finger-sticks. On a 32 bed floor of mostly LTC residents, I might have something to pass on in report on maybe 5-10 of them and it's usually just ABT.

If I've got a PRN nurse or a new nurse, I'll go into a bit more detail, like how they take their pills, if they're alert and oriented x 1, 2, or 3, are they verbal, do they need a hoyer lift, are they a feeder, are they on O2. Most people let me know what they need from me in report and aren't afraid to ask questions.

[BoyNamedSue]

Thanks for all the responses. I've finished my second week on sub-acute, which has been very crazy. I like to ask questions to my coworkers to see how I can improve for the next day. At first, I think this annoyed a few of them, and I was struggling with report especially, leaving out a few bits of information here and there. It made it difficult to get better with the feeling that some people thought I was dumb. On one late night, though, I was very busy (and ended up staying till 3am:wacky:); I had a lot of things to do still, so when the night nurse came on I sat down and just belted out what I thought was important for my patients. The night nurse didn't have any questions, and, for once I felt a little confidence in myself - having been tired and unwilling to dwell on what the other staff thought of me. It ended up being a thorough enough report, and the last few reports have gone well, too. I still need to work on my report-giving, but I now need to work on time management, assessment skills, and prioritization. Thanks everyone!