Report sheet

Specialties Psychiatric

Published

I work prn in a unit that's primarily CD detox, depression, some geri, psychosis, etc. The unit uses a self-designed report sheet that's 3 patients to a page, which I don't like (not enough room for everything). The unit where I work full time uses an SBAR (although it's not perfect either). I've decided to design my own sheet, with one patient per page because I like to keep my nursing notes, MARS, etc. organized in a binder w/ a pocket per patient. Does anyone have a psych report sheet you use and like? I can put together my own with no problem but someone may have a better one than what I've designed in my head. TIA!

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Specializes in psych, addictions, hospice, education.

would you mind sharing yours? I've yet to see one I like for psych!

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Sure, when I get it done. You'll have to remind me. I can't remember squat. ;)

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Specializes in Behavioral Health.

This is related but a little off topic. Our new manager wants us to be like "the other nursing units" which of course as a 22 bed, mixed CD and general psych unit, it is not. She is not in favor of a taped report for all oncoming staff to listen to (we can ask questions of the outgoing shift after we have listened to the tape) she wants live nurse to nurse report. That leaves out the psych counselors that are working in the milieu. Our feeling is that it is in the best interest of maintaining the therapeutic milieu for all staff to know what is going on with all the patients as it does impact care. I'm just wondering how other units are doing it and is there a format they are using to help keep the report time manageable, as report has become too long in attempt to cover all the "juicy bits" she insists we are missing.

Thanks in advance:)

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I prefer to-the-point face-to-face report but that can take too long in some places. Where I work full time, we talk off the SBAR, which keeps it focused. How, specifically, does your manager want to be like "the other nursing units"? It always fascinates me how hospitals want psych units to act the same as med/surg when it's like comparing apples to oranges. People who want that never spent any time in psych.

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This is related but a little off topic. Our new manager wants us to be like "the other nursing units" which of course as a 22 bed, mixed CD and general psych unit, it is not. She is not in favor of a taped report for all oncoming staff to listen to (we can ask questions of the outgoing shift after we have listened to the tape) she wants live nurse to nurse report. That leaves out the psych counselors that are working in the milieu. Our feeling is that it is in the best interest of maintaining the therapeutic milieu for all staff to know what is going on with all the patients as it does impact care. I'm just wondering how other units are doing it and is there a format they are using to help keep the report time manageable, as report has become too long in attempt to cover all the "juicy bits" she insists we are missing.

Thanks in advance:)

We use a set of blurbs. Besides charting on your assigned patients, you also do a blurb on the shift report (a Word document). Under each pt's name there is a spot for a blurb and the Overt Aggression Scale score for each 8 hour shift. The med nurse adds all prns and their effectiveness, time given, etc. This shift report is read aloud at report along with the pertinent info from the Kardex to everyone on that shift. When the charge nurse goes to rounds with the doc, care manager, pharmacist, etc., the blurbs are the main source of information, not the chart. We save the blurbs, but they are not part of the chart (legal document). Mostly I like this system. I only see two problems: There is some inconsistency in the style of blurbs, so we should probably hammer out a sample format. Also, on day shift one of the charge nurses does all the blurbs on all the patients. I feel this is not fair to her and that everyone should do their own blurbs instead of waiting for her to do them. I think it is just a bad habit day shift has gotten into. My blurbs are always a less formal version of my charting, sometimes with a few extra details added that are pertinent but not necessarily needed in the chart. Hope this helps.

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Specializes in mental health; hangover remedies.
We use a set of blurbs.

Have used identical method and find it the best. The clinical notes are there for the verbose handover - the blurb (love the name - is that the ward name for it or yours?) - was vary scant note on anything to report; who went on leave; appointments, etc - so it worked as a ward clinical summary and an operational tool.

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Specializes in ER, Acute, home health, LTC, & Psy.

did ya ever make a psy report sheet? can i get a copy?

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Specializes in mental health; hangover remedies.
did ya ever make a psy report sheet? can i get a copy?

Our report sheet was a blank piece of lined paper - we wrote the relevant pts name on there and summary of the event...

Eg:

Ted Smith: Adm. 14:00 S48/49 (assault) Dx Paranoid schiz; Depot last given 4 days ago. s/b psych

or

Bob Jones: Fell out of bed at 0400. Nil injury evident. Incident form complete.

We wouldn't write anyone in who had little of clinical note to report. Eg

Jane Lewis: Got up 8am; ate breakfast and has watched TV all morning.

So in the end you get a summary of the 'key players' for the day and can keep a simple review of trends or incidents.

As a shift supervisor - anyone who got reported x3 days in a row - I made a point of seeing them (or anyone with serious event obviously).

So yes I can send you a copy of a blank lined piece of paper - would you like that as *.doc or *.ppt? :smokin:

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Sure, I'd like to see a copy. Would you PM it to me? .doc is fine.

Thanks!

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