At report-off time...

[arv]

What exactly do you tell your nurse when you are reporting off? I usually end up telling her everything I can think of because I am afraid that I will leave out some important information. I don't want to waste her time, but we were never told what to say, just to report off! :) Did anyone else either get any guidelines, or can a RN let me know what she wants to hear (vitals, status changes, etc.) Thanks in advance!

[Daytonite, BSN, RN]

I don't have any links, but this subject comes up in the First Year in Nursing Forum with some frequency. Mostly because the new nurses are getting guff from some of the older nurses because they either are not giving enough information or they are giving too much.

The answer to your question is that it is hard to know the right answer to that. A lot has to do with the person who is taking the report and what they consider important. In general, you want to report significant happenings that occurred on your watch. That could be anything from a procedure that patient underwent to some big discussion with the doctor or the patient's family about their care. I always try to report order changes in medications or treatments, any new lab or tests that have been ordered, any abnormal test results that came back and who was told about them and what was done about them and any incidents that occurred. Sometimes a piece of equipment is not able to be obtained and you get a call from central service telling you why--you need to pass that along. I always try to keep in my mind what I would want to know if I were the person coming along and taking over the patient's care.

I think it is interesting that you pose this question. I was just reading a news item in my latest copy of Nursing 2006 on patient handoffs and JCAHO wanting to implement standards whnever patients are transferred between units of a facility, transferred to another facility, or during shift changes because of poor communication. Patient safety is at the heart of this. I can only imagine some of the things that can go wrong when people fail to communicate important information. This whole JCAHO business will probably result in more paperwork for us. Most facilities already have transfer sheets they use when patients are transferred from one facility to another. I think, however, that JCAHO is looking more at what is going on within the walls of facilities. Somehow, I think that standards for shift report are going to end up being included in this.

[jschut, BSN, RN]

I tell if pt is on an ATB, reason why, any different behaviors noted, any new incident reports, and the like...pretty much the pertinent stuff..

But then again, I work LTC and only on the weekends, and the nurses I see are most of the time also weekend shift nurses. You have no idea how many times I have run across things that haven't been done or haven't been told to me because I do work weekends. It gets very frustrating sometimes to have to deal with that.

But, I only have a bit over a year to go!

[VickyRN, MSN, DNP, RN]

I have attached an excellent guide for giving report: Situation Background Assessment Recommendation (SBAR). Hope this helps :)

Toolbox Appendix.doc

[Nemhain]

I have attached an excellent guide for giving report: Situation Background Assessment Recommendation (SBAR). Hope this helps :)

Ooooh great resource Vicky!