advice about hand off reports

David's Harp · Dec 1, 2007

When I give a hand off report I feel like I'm not giving the appropriate information even when I follow the SBAR format. Any advice on giving a better report?

I don't find SBAR to be as useful in giving report as it is in communicating w/ physicians & other nurses regarding present issues needing immediate action.

For change-of-shift report, which has really been a struggle for me, I have a little section at the bottom of my "brain sheet" with the following rough outline of what will be needed:

-Demographics (name, age, gender)

-Allergies, risks (falls, aspiration, etc.)

-PMHx

-Chief complaint

-Story of present visit (salient points, not minute-by-minute - some pts are there for a month or more!)

-Plan (if known)

-Systems, including skin (& any interventions being done)

-Pain mgmt

-IV access, IVF if there are any

-Issues during last shift

-Unusual Labs, interventions being done

-Labs needed

-Rx that need mentioning (Heparin, any drips, anything needing special mention)

-Any heads-up (family, behavioral if not already covered in "Systems", restraint orders that will need renewing, etc.)

I try and fill these in throughout the shift if I can, but if not at least i have the blank outline to guide my thought process. Some of these bullet points lead to others out-of-order, but at least I have it all in front of me.

Hope this helps a little bit!

-Kevin