Hello! I am a new graduate and staring out on an orthopedic unit. I'm having trouble determining what is important and what is not important to write down during change of shift report. Does anyone have good templates of what I should be writing down? Thank you!!
Jul 28, '17
I work on ortho. You don't need a whole lot to give in report on our floor. Some nurses really over-complicate it.
What I want to know in report.
Vitals signs stable/unstable. How well they are transfering/moving? CPM times (if you use CPMs) or other equipment you use. How pt has been managing pain. Last PRNs time given and which PRNs you have needed. Dressing - clean, dry, and intact? Any drains? Labs only if significant. Any antibiotics that are due and around what time? Any significant background history or abnormal assessment findings. I honestly don't want to know any more than that. I don't need their life story. I don't need every detail of their past history and I don't care about labs if they aren't significant. I'll let people know which equipment is already set up and whether secondary tubing is already set up too. This saves a step for the oncoming nurse so they know they need to grab that stuff.