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- by Maddy_Rose May 4Hi there, I'm a new grad that will be starting on a orthopedic/vascular surgery floor very soon. I feel...OK about my ability to communicate the most important information about a patient to another nurse, but I want to get better at giving a more thorough and logical report (I mean not jump around in my thoughts as much).
We use kind of a combination of verbal and written report on the floor - if nothing notable happened with a patient we might just write a little blurb about them for the nurse coming on to read. But if a patient is new or had a lot of stuff go on a verbal report is usually done. Do you guys have any tips or strategies for organizing your thoughts, or the best way to give a thorough picture of a patient? What's the most effective order of information you find works?
Any input is much appreciated!
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- May 4 by lmccrn62My unit uses SBAR and we do at the bedside. This eliminates lengthy report with information that is not useful.
- May 4 by EMT2BSNI 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!
- May 5 by westieluvI work nights, so there may be a little more time to do this than if you work days, but I always make it a point to take a few minutes to look through each of my patients' charts and jot down any good information from the doctors' progress notes from the previous day (if I can read them, lol), any abnormal lab values (or normal ones if the expectation is that they would be abnormal, e.g. telling the oncoming nurse that a patient who was admitted with a UTI now has a negative UA/culture), and any diagnostic test results from the past 24 hours. It is amazing how much you learn from doing this, because a lot of times the nurse that reported off to you either didn't have the time or didn't bother to take the time to look anything up. I often get told by the day shift nurses that they love getting report from me because it is so thorough!
- May 9 by clezallawe do bedside report and try to involve the pt. in the report process. SBAR is a great way to start. Try to include information the oncoming shift will find helpful to the care of the pt for the shift. A "complete" history in change of shift isn't always necessary ie: 80 yr old female here for chest pain and general weakness had hysterectomy at age 43( not really important information) what i want to know from off going shift is mentation( are they alert) how they ambulate, IV site and when was it put in fluids, foleys( when put in) abnormal labs, tests for AM. PAIN level last meds given. Please don't give me a complete assessment as I have to go and assess pt. for myself. Follow head to toe and if pt is able ask them how there day was and do they understand plan of care. Good luck, you will find your own style.
- May 10 by MGoldRNThought I would chime in on this topic since giving report is done so many different ways. At the hospital I work at, management is making the push to eliminate nursing station reports. The new drive is to do bedside report with SBAR style folders/worksheets. Some units are doing better than others with compliance. The telemetry unit that I work on is probably the least compliant. The folders that we use for patients often have incorrect information, outdated notes, and lack sufficient SBAR quality. Some of the nurses attempt to do bedside report, but it usually does not work out too well for us. Unfortunately, most of us are creatures of habit, so we enjoy a good verbal report. However, while I do enjoy verbal report, I am a huge advocate for eliminating unnecessary information. One of my biggest pet-peeves is when a nurse receiving report expects a full h & p. As some of the other posts noted, I find it relevant to communicate a brief synopsis of the patient's status, how they ambulate/toilet, iv site w/ meds, telemetry strips, relevant labs, plan, code status, skin integrity, and any other relevant information. I think it is redundant to speak about every single XRAY the patient had, the full history, and what the patient ate. I get so frustrated when people bend my ear for 15 minutes about information that I can clearly read myself.
- May 11 by lolaviexI just finished my preceptorship in med-surg and I got really good at rattling off patient data and what had happened throughout the night. But when I was asked, "so what's the plan for today?" I froze. Don't forget to know that!
- May 14 by Maddy_RoseGood point MGoldRN! I feel kind of silly when I list of a bit of a patients medical history then realize halfway through I don't really need to when they can just read. Would you (or any other repliers) say this would be a the most important information to communicate:
Tubes (IV, feeds, chest drains)
- anything else notable (ex. critical labs and treatment, etc.)
- May 15 by brilloheadQuote from Maddy_RoseDepending on how the eMAR is set up, I also like to know when they last had pain meds and what's been working for the patient's pain (how much, how often, ice packs, positioning). I like to stay ahead of pain rather than chasing it, and depending on the software at your facility, it may take some digging to see how often they have rec'd pain meds and how well they responded to them.Good point MGoldRN! I feel kind of silly when I list of a bit of a patients medical history then realize halfway through I don't really need to when they can just read. Would you (or any other repliers) say this would be a the most important information to communicate:
Tubes (IV, feeds, chest drains)
- anything else notable (ex. critical labs and treatment, etc.)
Hearing, "one Norco q4h has been keeping him at 3 or less" can save five minutes of digging through the system for the info, and if the call light goes off before I have a chance to go digging, I know right away whether they can have pain meds now or if I have to tell them it will be another hour, etc.
As for "anything else notable" -- I also like to know if there are any tests scheduled for that day. Again, this depends on the facility and the software, but sometimes you have no way of knowing when something has been scheduled for until Transport shows up to take your patient off the floor. If I know someone will be going for a scan or something at a certain time, I can let the aide know to wait until later for bath or linen change, and I can also administer pain meds beforehand as needed so the patient is comfortable during the procedure.
- May 16 by MGoldRNSure, I feel it is necessary to quickly state the patient's current hospital course (even though some shift care summary reports will state the admitting dianosis). Code status is definitely a must. The patient's mentation is important. Pain is relevant to know. Any kind of tubes that you mentioned. Skin status is often overlooked, and I feel that it is important to note. Ambulation status is sometimes overlooked as well. However, I often think of ambulatory status as an important factor. Relevant labs and whether or not measures were taken to rectify them. A quick overview of the patient's plan is always helpful.
I always try to think of it this way, do not sound like a verbatim account of the patient's chart. Just let the report flow naturally and make it systems-oriented just like an assessment. The emergency dept in the hospital I work at has an awful time reading the patient's ED chart verbatim while giving report. On many occasions, I have had ED nurses tell me, "Hold on while I pull up the chart so I can read it to you." I had to stop one time and tell them this isn't nursery school, and I do not need bedtime stories read to me. I told them to please tell me about the relevant interventions you have provided in the ED, and if you are unable to do so then please just send the patient up. I don't know if this particular style of report has to do with our ED practicing in "team nursing." Which is essentially one nurse never has a full assingment, they all swap tasks and mingle between rooms. Call it chaotic if you ask me.