Giving report in LTC

suebird3 · Jul 11, 2006

My facility uses the Census sheet. I give any pertinant info on what has happened to whom. If there is no problem, I say "No problems".

Suebird :)

CanadaProud · Jul 11, 2006

Night Owl,

I am still a student, but I can at least tell you what I saw when I was in hospital. We all did sit in the report room, but each nurse from the shift before us spoke into a tape recorder before the end of their shift. They would make note of changes, and special information that we needed to know about each patient whether it be discharges, treatments required, etc. We would then listen to the play-back for all patients. As well, either before, after or during report each individual nurse would look at the kardex ONLY for his/her own patients. I found that this went pretty smoothly, and quickly since we could do some of the most of the research & "backround checks" on our own.

Cheers!

CoffeeRTC, BSN, RN · Jul 11, 2006

This is LTC, right?

Okay, assuming that you've worked on the same unit before, we just use our census sheets and go down the list with any new updates, etc. If it is a new admit or if the nures hasn't worked there before, then what I do will include main dx, LOC/ orientation level, pills whole or crushed and IVs or wounds that they need to know about.

Lets face it, most residents history doesn't change much and depending on the skill level of your LTC, not everyone is gonna have that many changes.

BTW, we havent used a Kardex in years.

jetscreamer101 · Jul 11, 2006

In my LTC facility, we have shift notes that have all the residents on that particular wing/section. Report is generally taped, but sometimes an oral report is given to the oncoming shift. Some nurses just hit the high points on those residents that have something going on with them, others give a mini-report on each resident.

Daytonite, BSN, RN · Jul 12, 2006

Some of the nursing homes I worked in taped report, but this was for the Medicare wing of patients where things were changing rapidly so the report was pretty much like a hospital report. Otherwise, many places I've worked had that illegal report book at the nurses station where we would write things in it like falls, skin tears, what doctors were called for orders and other patient problems that might have come up. You could give report from that most of the time. I always wanted to know who was on an antibiotic or had had a recent fall or skin tear because we had to do special charting on them. The majority of the patients are status quo and nothing more need be said about them.

LoriAlabamaRN · Jul 12, 2006

Here too we simply use the census sheet with any changes written out to the side. Report is frequently very quick, since everything that needs to be known is written on the sheet.

night owl · Jul 12, 2006

It seems that our facility thinks Jacho wants us to use the kardex and go through each pt, one by one with age, Dx's blah, blah, blah which is absolutely crazy. I can understand doing this in a hospital setting where pts come and go all the time with changing conditions, but in LTC? I don't see the need unless maybe you're giving a report to a new nurse that's working in a certain district or hallway and wants to know every detail or maybe to a floater, but we always used a census sheet and went down the line like everyone else. And that illegal report book? I really miss it. I think it was the best way to communicate from shift to shift and from day to day. Why is it illegal?

luvmy2angels · Jul 12, 2006

We use our census sheet too. We give verbal report to the oncoming nurse and usually just tell of any unusual events that happened, any new orders or labs that came in, escpecially PT/INR results, any falls, laxatives that were given. I work 2nd shift our oncoming report usually is 15 minutes, our offgoing report is usually 20 minutes ( the night shift nurse asks ALOT of questions).

tatgirl · Jul 12, 2006

We too use the census sheet for report. If anything is going on with a particular resident ie antibiotics, falls, etc we pass it on to the next shift. Report for the 25 residents normally takes about 10 minutes or so. Longer if a certain night shift nurse works (who asks alot of questions!!)

Wendy

LPN

CapeCodMermaid, RN · Jul 13, 2006

Why do all y'all call the report book 'illegal'? Every facility I've ever worked in has one...we're told it's a regulation.

Daytonite, BSN, RN · Jul 14, 2006

Why do all y'all call the report book 'illegal'? Every facility I've ever worked in has one...we're told it's a regulation.

For the very reason that if the state comes in and finds things in that report book about changes in patients conditions, etc. that never got addressed in the individual patient's charts, the facility is looking at big fines. In the places where I've worked where we had a report book, it disappeared very quickly and was put into a locked drawer or somebody's locked car when the state surveyors walked in the door and didn't reappear until they left.