Help: What does med pass & shift report look like in your facility?

  1. I started at a new facility last week that has a detox unit and a residential treatment unit.

    Since it is new there's only about 4 clients.

    My experience is from psych hospitals, including a dual diagnosis unit.
    However I'm looking for help in how other do things in their own facilities, mainly detox, so that I can suggest ways for us to improve.

    For med pass:
    Right now we have a med cart, and med cups. With 4 clients it's easy to just write the initials on the cups. But I don't see this being a good way for when we're up to 30 pts.
    Im thinking of suggesting a tray for cups with clients names already on the slots?
    is there another way?

    for shift report:
    We have no kardex, no pt binder. Everyone just goes over what they think is important to pass on per client. The problem is I feel things are missed, there's no consistency, and again not a feasible option once there's 30 clients.

    Ive made a little template for myself that includes the clients name, age, allergies, status, space for history, additional info and last PRNs

    I requested a pt binder, DON said she'll make one. what do you guys use? What does you kardex consist of?
    for report do you use a brain sheet? What information do you make sure to pass on?


    My facility doesn't have any standard policies written out for preferences regarding these matters yet. Nor regarding documentation.
    Any examples or help will be extremely useful for me to give to my DON so we can run smoothly before more patients are added on.

    please feel free to DM if you prefer

    Thank you ahead of time!
  2. Visit KaffeineFiend profile page

    About KaffeineFiend, ASN

    Joined: Mar '16; Posts: 19; Likes: 26
    Specialty: 7 year(s) of experience in Psych

    4 Comments

  3. by   NRSKarenRN
    YIKES--no policies??? Is this a new startup company? It's DON's job to create P+P manual; kudos to you willing to help. Prepouring meds into med cups/trays is patient safety issue; pharmacy + DON should create poliicy for safe administration.
  4. by   KristieRae71
    Your DON should have definitely had some policies or standards of care in place before this place even opened! However, that being said, I suggest that you find out who regulates your place of employment. Is it DNV? Joint Commission? There are some regulations that they may have that can make a difference. Our facility uses an accudose machine, but we are part of a hospital. We DO have a large binder with pockets (like zipper pouches) that we can use if we want to "set up" medications. This way nothing has to be opened, everything gets scanned and we stay in compliance with DNV. Our reports are verbal handoffs. Each nurse gives report on her group of patients to the oncoming shift. The idea is to use SBAR in handoff but the reality is more like what you described probably. We have around 20 patients on average for each unit. Good luck!
  5. by   hppygr8ful
    Quote from KaffeineFiend
    I started at a new facility last week that has a detox unit and a residential treatment unit.

    Since it is new there's only about 4 clients.

    My experience is from psych hospitals, including a dual diagnosis unit.
    However I'm looking for help in how other do things in their own facilities, mainly detox, so that I can suggest ways for us to improve.

    For med pass:
    Right now we have a med cart, and med cups. With 4 clients it's easy to just write the initials on the cups. But I don't see this being a good way for when we're up to 30 pts.
    Im thinking of suggesting a tray for cups with clients names already on the slots?
    is there another way?

    for shift report:
    We have no kardex, no pt binder. Everyone just goes over what they think is important to pass on per client. The problem is I feel things are missed, there's no consistency, and again not a feasible option once there's 30 clients.

    Ive made a little template for myself that includes the clients name, age, allergies, status, space for history, additional info and last PRNs

    I requested a pt binder, DON said she'll make one. what do you guys use? What does you kardex consist of?
    for report do you use a brain sheet? What information do you make sure to pass on?


    My facility doesn't have any standard policies written out for preferences regarding these matters yet. Nor regarding documentation.
    Any examples or help will be extremely useful for me to give to my DON so we can run smoothly before more patients are added on.

    please feel free to DM if you prefer

    Thank you ahead of time!
    Exactly what kind of facility is this that does not have clear policies and procedures? Is tis in a hospital setting or a private rehab facility. The whole rehab industry is currently under intense scrutiny due to the fact that they are under regulated and profit driven and people are dying in them.


    I have worked in a legit acute hospital with detox and rehab for many years and would be happy to share input with you.


    Hppy
  6. by   angeloublue22
    I opened the detox I'm in and have worked in addictions for 8 years. We can only have up to nine clients so we have what we call "The Brain" on the one side we have all general info, like what would be contained in a facesheet. In middle we have alerts and on the other side we have the actually daily report split up night/day shifts. It's on going and only gets deleted when the client discharges.
    At the other facility we had 24 clients and we kept and binder organized by bed number with pretty much the same info as above. They were both very useful and way for everyone to bee on the same page and see the way the pt's behavior progresses through out their stay. You need an ongoing report sheet any way you slice. It's definitely odd that you don't have one. Good job taking the initiative.

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