I work on a med-surg floor and we give verbal reports for all of our patients. The basic flow follows a head-to-toe overview of the patient and goes something like this:
Name and Age
Primary Diagnosis/Reason for admit
Oxygenation (Room Air/O2/Trach/Vent/etc)
IV access (and anything running like TPN or IV fluids)
Dialysis Access (dialysis days and last output)
Telemetry (if so, rate and rhythm)/Pacemaker
Feeding Tube (type of feeding and rate)
Urinary continence (Foley/Urinal/Bedside commode)
Bowel Continence (typical stool, CDIFF, Flexiseal, etc)
Wounds (pressure ulcers, wound vacs, type of dressings, surgical wounds, etc)
Pain management (location, medication preferred and when last given)
Other PRN medications given
Diabetic? Accuchecks (last values)
Abnormal Lab Values (and any treatment given)
Any other pertinent information (family dynamics, patient preferences, things that need to be completed like labs, dressing changes, blood, etc)
A typical report would go something like this:
So-and-so is a 68 yo female here for acute respiratory failure and chronic renal failure
A+Ox 2-3 with periods of confusion (especially at night-time), mouths words and uses clipboard to write
On a T-piece at 30%, capped during the day, in process of weaning. Sats normally 95-98%
Left arm PICC line, triple lumen, draws blood. Nothing running.
Right chest vascath, dialysis M, W, F. Last output was 2L.
On tele, sinus rhythm with occasional PVCs, 70s-80s
G-tube running Glucerna at 50ml/hr continuous tube feeding with residuals of 10-20ml
Foley cath with scant brown urine
Incontinent of bowel, frequent loose stools, positive CDIFF
Stage 3 sacral wound with wound vac at 125mmHg, dressing intact
Dependent edema 2-3+, especially in hip and lower legs
C/O pain in sacral area from pressure sore, Dilaudid 2mg Q4 hours PRN, last given at 1800 (asks for it round-the-clock)
Accuchecks Q6 hours, last values 122 and 156, 5 units NPH given at 1800
Mg and K have been low (1.3 and 2.8), given riders for both, lab redraws scheduled for tonight
Family at bedside, daughter has power of attorney and calls frequently throughout shift for status updates. Patient needs 2 stool cultures taken by end of shift.
Hope that helps!