Advice On Shift Report Needed!!

TexasPediRN · Oct 14, 2005

Do you use Kardex'es?

I always found using them helped. I too HATED giving report at first, but during my first days one of the girls sat with me and pointed to which section to talk about next, and after that I dont mind report! I just needed help getting the 'flow' down!

If you go section to section, and talk about meds, iv's, nursing things to do, etc, then go into anything out of the ordinary, any dr's that were in, etc.

After all the info on our kardex, you would go into pt lung clear, bowel sounds present, iv site patent, etc....

I hope that helps a little bit!

Also, ask someone to go into report with you and help you! Or, listen to them tape report! After a week you'll be a pro!

Dorito, ASN, RN · Oct 14, 2005

Keep it simple. I like to hear report about things that are ABNORMAL, not an entire assessment if it's within norms. Also mention any abnormal labs, xrays etc. Also, make sure you let the staff know about any labs/tests/procedures that the patient will be getting so they know about preps etc. Let the staff know if the patient received any prn's during the shift. You'll get good at it eventually- don't be so hard on yourself. We've all given crummy reports over the years. Our minds may wander if it's been a tough shift etc. If something changes after you tape report just let the nurse know when they get out of report.

Thunderwolf, MSN, RN · Oct 15, 2005

Please, do not read the report off the Kardex...read it from your notes...abnormals, significant occurences, changes in condition, which docs saw or yet need to see the patient, what significant nursing tasks have been done and yet need to be done, and patient readiness for discharge. Please do not read your report from the Kardex...I can read it myself or have already read it. Time is valuable...so is good information.

Nurse-o-holic · Oct 15, 2005

I try to read my shift flow sheet left to right:

Vitals, IV, any attachments (ie. Chest tubes, epidural, etc.), relevant meds, tests/procedures, lab work, what happened that day and mentioning any significant goings on, and end it with the plan (ie. plan for discharge home with home care in 2-3 days)

After repeating this process for each patient it became quicker for me to tape and get out of report more efficently. It seems to work because we don't have kardexes so there's no repeating the story!

It seems like you have a mind for detail, and that's not a bad quality! Way to stay positive!

Daytonite, BSN, RN · Oct 15, 2005

I try to read my shift flow sheet left to right:
Vitals, IV, any attachments (ie. Chest tubes, epidural, etc.), relevant meds, tests/procedures, lab work, what happened that day and mentioning any significant goings on, and end it with the plan (ie. plan for discharge home with home care in 2-3 days). . .After repeating this process for each patient it became quicker for me to tape and get out of report more efficently. It seems to work because we don't have kardexes so there's no repeating the story!

Very good recommendation! Just because other nurses are criticizing your reports doesn't necessarily mean they are not up to snuff. Some of the more experienced nurses might be playing the one-up-manship game with you just to feel important and deliberately make you feel bad. When I had to tape report on the stepdown unit I worked, there were 3 of us RNs giving report over a half hour. I always kind of figured I had 10 minutes to tell my "story" and so I tried to limit my recording time to 10 minutes.

Here are a couple of recent threads with some shift report advice on them:

https://allnurses.com/forums/showthread.php?t=120811&highlight=shift+report

https://allnurses.com/forums/showthread.php?t=122196&highlight=shift+report

ncbeachgrl · Oct 24, 2005

Just like every nurse on your unit does it differently, all of us here on the message boards will tell you diffently as well! :) Kardex's are great if they're set up right. The unit that I float to does recorded report but everyone has the same guidelines for taping so it makes it pretty straightforward. On my unit now, I am the only who goes through body systems. This report might take all of two minutes longer than most, but I never miss anything this way. Reporting on abnormal things only is great, but I have found that for my unit, it leads to people skipping all around without any particular order, and information gets missed. (This may only be my unit though). Even if an infant is on room air, I say so, because many times after report from the offgoing nurse, I've walked over to the bedside and seen that the patient has a nasal cannula. I do agree with what someone else said, listen to other people give report and ask nurses what the guidelines are for giving report. You will never please everyone's expectations (welcome to nursing) but as long as you cover the basics, and remember to report abnormal lab values (or even just say, "labs are WNL"), you should be okay. And don't forget to stand up for youself! I know it's hard at first, but if you don't, you will become very unhappy quick!

justmanda · Oct 24, 2005

I need major help with giving a good shift report. I hate doing it and feel very self conscious about it. Where I work, we tape on each patient using separate tapes. I take what I received on the report I received and add anything of importance to it from my shift when I tape for the next shift. Regardless I know I'm terrible. I can just sense nurses think my reports stink. Today one nurse mentioned it to me in her "nice" way. She has been a nurse for only a year, but knows everything!?! She said my reports are too long and in no order. Apparently a good report is following her report format, even though each nurse has their own forms they've made. My reports seem like they get longer especially since one nurse snapped at me for not mentioning a past issue from two days earlier which was over and done with. She asked me about it, I answered it and she snapped "you couldn't mention that in report??!!!" as if I left out a major issue. I receive reports where I have to look up stuff and don't always feel this is a reflection on the nurse. Often she barely has time to tape at all. I've beeing a nurse for all of three months. With my preceptor, she made it a common practice to trash the reports we were listening to. I can't tell you how that made me feel, thus the reason for feeling so self-conscious now. She wasn't just making a few comments, but saying how this girl "s_ks" at giving report. She swears constantly and I hate how unprofessional she is, but of course she thinks she gives a great report herself!! You'd think only good nurses could give good reports.
Do any of you have suggestions for giving report and in what order? How far back do you need to give info (ie previous tests, procedures, etc)? I wish I worked with a good group who would help and not back stab and be so hurtful, so I'm praying you all have good suggestions Thanks so much.

I give report by problem. For example: Patient was admitted with Uncontrolled HTN....adjusted meds, problem is resolved. Patient developed fever while here....BC done, on ABX. Patient's COPD exacerbated...on resp. treatments, IV solumedrol. New Afib: cardiology saw her, started her on lovenox and digoxin, rate controlled, etc. I start off with a brief pt history, tell them if they take pills okay, walk, pee and then I head into my problem list. Takes about 2 minutes a patient and everything pertinent is covered. THEN...if a doctor walks up and asks "Why was I consulted on this patient?" you always know.

TypicalFish · Oct 24, 2005

I need major help with giving a good shift report. I hate doing it and feel very self conscious about it. Where I work, we tape on each patient using separate tapes. I take what I received on the report I received and add anything of importance to it from my shift when I tape for the next shift. Regardless I know I'm terrible. I can just sense nurses think my reports stink. Today one nurse mentioned it to me in her "nice" way. She has been a nurse for only a year, but knows everything!?! She said my reports are too long and in no order. Apparently a good report is following her report format, even though each nurse has their own forms they've made. My reports seem like they get longer especially since one nurse snapped at me for not mentioning a past issue from two days earlier which was over and done with. She asked me about it, I answered it and she snapped "you couldn't mention that in report??!!!" as if I left out a major issue. I receive reports where I have to look up stuff and don't always feel this is a reflection on the nurse. Often she barely has time to tape at all. I've beeing a nurse for all of three months. With my preceptor, she made it a common practice to trash the reports we were listening to. I can't tell you how that made me feel, thus the reason for feeling so self-conscious now. She wasn't just making a few comments, but saying how this girl "s_ks" at giving report. She swears constantly and I hate how unprofessional she is, but of course she thinks she gives a great report herself!! You'd think only good nurses could give good reports.
Do any of you have suggestions for giving report and in what order? How far back do you need to give info (ie previous tests, procedures, etc)? I wish I worked with a good group who would help and not back stab and be so hurtful, so I'm praying you all have good suggestions Thanks so much.

We give verbal report to our oncoming nurse; I start out with an intro age, H/P, chief dx, etc; pressing issues of the day, labs,x-rays, surgeries; main problem or goal; then I do the systems, including IV's. most nurses on our unit use one of two brains, but they are basically the same. Also, remember that as long as you cover the above info, you're ok; you won't please all of the people all of the time, just be accurate, efficient, and don't digress into some long narrative. Good Luck.

Oh, and P.S. I have gotten burned by bad reports, we have to present our pts on rounds, so you need to know what's what. Now, I make sure that I have time to read the H/P and/or progress notes. Recently, I was told that a pt was in the ICU for "respiratory distress and Pneumonia", when actually that was his admitting dx for the m/s unit; he was in the ICU because he coded on the floor with PEA. The nurse either didn't know, or didn't bother to tell me.