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Any report tips out there?

Posted

Has 1 years experience.

As an ER nurse, well any nurse for that matter, we are faced with giving report.

I may be biased, but I feel like report is given a lot more frequently in the ER since we are constantly transferring patients to other floors.

With that being said, I would love to hear some advice from all my fellow nurses on here.

What do YOU think is important to be relayed in report? More importantly for my sake, if you're a floor nurse, what do you 100% for sure want to hear when getting report from the ED?

Here are some things I was taught to for sure include:

basic patient info

age/ gender

chief complaint/ admission reason

IV or any venous access

diet

plan

After talking with a couple friends of mine on floor units they all agreed that the way the patient gets around is really important (which I'm sure we all inevitably add into our report anyways) and also skin condition.

I feel like its truly difficult to get a thorough and accurate skin assessment on ER patients as we typically do focused assessments and don't always have the opportunity or time to do a complete head to toe.

Anyways, add your input on here and lets share some advice for other new grads out there trying to perfect their report giving skills!!

I like to know the basics: why they came to the ED, how they get around, and their general mental state (alert & oriented, dementia, suicidal, anxious, etc), and what you guys did (at my ED, not a whole lot of charting occurs), I'm usually good.

I like to know how they get around because grandma may say she's fine getting from the cart to the bed, but, in reality, she's half blind, has fallen 14 times in the last year, and uses a walker. I like to know the mental state because I may need to get a sitter and that takes time. And sometimes, I change my approach to establish a better rapport.

The IV, diet, age and gender is in the chart or I'll figure it out. I know you guys don't have the time for a skin check and I have to do one anyway, so I'll figure that out.

The plan would be nice, but that's probably in the chart too. And, honestly, I probably have a good idea what the plan is based on why they were admitted. So, unless its something unusual, I probably don't need that info, but I certainly wouldn't object.

Of course, I'm one of those nurses who doesn't need the person's life history in report. Why are they here, how to they void, and how do they move. Done. I know there are others who like to hear every minute detail, but I'm not one of them.

perfectbluebuildings, BSN, RN

Specializes in Pediatrics.

One thing you didn't mention, that you probably already do anyway bc it's so basic, is any medications the patient received and about what time they received them. It's so helpful to know e.g. if they've had any pain medicine, or a first dose of antibiotic or anything for fever... well, you know. :-)

Thank you for this post; I think I will learn a lot from it as well.

ICU-BSN

Specializes in Trauma ICU. Has 3 years experience.

Why they are there, what was done for them in the ED, IV access, any other line/drain/tube that they may have. A last set of vitals is nice on my unstable patients. I also like to know if any next of kin is present since many of my patients arrive to me sedated or otherwise unresponsive.

I think a huge consideration here is what kind of computer documentation is available to the receiving nurse.

I have yet to meet a human who can speak as fast as I can read. It takes me literally around a minute to get all the HX I need from H&P or ER doc summation.

I think what is most important is to give a clear concise picture, and include information not easily obtainable by the receiving nurse. The big picture. "PT came in hypoxic in the 70s and hypotensive in the 80's. Intubated, sedation being managed with IVP fentany and versed, dopamine running." Exact BPs, location of IVs, diameter and place (at lip or teeth) of tube is all easy enough to find.

That being said, that is not what I do. Well, it is when I am giving report to an ER nurse, or a float pool nurse who is competent in ER nursing. Otherwise, I try to give a report that will make the receiving nurse happy. To do this, I always open the exact same chart equally accessible to receiving nurse, and read off stuff so they can write it down. I do this knowing full well that by interjecting two opportunities for human error, I am decreasing patient safety. More accurately, I am participating in an anachronistic process that fails to take advantage of technology that can increase safety.

But, when I check the MAR for time and dose of Lasix, then check I & O so I can verbalize it and the receiving nurse can jot it down on their brain, it makes report go smoothly. And because report generally goes smoothly, floor/ICU nurses don't dodge me when I am trying to get a PT to the floor.

I feel like its truly difficult to get a thorough and accurate skin assessment on ER patients as we typically do focused assessments and don't always have the opportunity or time to do a complete head to toe.

Unless a skin issue is the reason for the ED admission do not worry about this. A focused assessment is what you are responsible for. Skin documentation, done properly, takes time and experience doing it over and over again. At the most, eyeball the bony prominences (head, butt and heels) on your patients with limited mobility looking for anything outrageous and report that to the physician and admitting nurse. Then be prepared to be asked what you did for anything you've found followed by a long list of whatever your facility uses for wound care that you've never heard of and do not have access to in your ED so you did not apply it. This will then be followed by a long disapproving silence which you have not felt since the last time you ticked off your mom and will make you think twice about ever going that extra mile again. Rinse and repeat.

For the rest of report I've learned that the admitting nurses found it helpful if I let them know what equipment they might anticipate needing (extra pump or suction,etc) because they often have to go on an expedition to find it which has to be supremely frustrating for them. Letting them know in report buys them some time and a lot less unnecessary running around.

Correct code status is a big one for me. Last week I admitted an ER pt to med floor. ER nurse stated pt was FC, papers I found while compiling the chart 1/2 hr after the fact read pt was indeed signed DNR.

Alexx_xox

Has 1 years experience.

I like to know the basics: why they came to the ED, how they get around, and their general mental state (alert & oriented, dementia, suicidal, anxious, etc), and what you guys did (at my ED, not a whole lot of charting occurs), I'm usually good.

I like to know how they get around because grandma may say she's fine getting from the cart to the bed, but, in reality, she's half blind, has fallen 14 times in the last year, and uses a walker. I like to know the mental state because I may need to get a sitter and that takes time. And sometimes, I change my approach to establish a better rapport.

The IV, diet, age and gender is in the chart or I'll figure it out. I know you guys don't have the time for a skin check and I have to do one anyway, so I'll figure that out.

The plan would be nice, but that's probably in the chart too. And, honestly, I probably have a good idea what the plan is based on why they were admitted. So, unless its something unusual, I probably don't need that info, but I certainly wouldn't object.

Of course, I'm one of those nurses who doesn't need the person's life history in report. Why are they here, how to they void, and how do they move. Done. I know there are others who like to hear every minute detail, but I'm not one of them.

Can I please give you report on all my patients? HAHA some of the nurses I've given report to expect me to give them the patients life story from birth up until the day they're admitted LOL!!

Alexx_xox

Has 1 years experience.

One thing you didn't mention, that you probably already do anyway bc it's so basic, is any medications the patient received and about what time they received them. It's so helpful to know e.g. if they've had any pain medicine, or a first dose of antibiotic or anything for fever... well, you know. :-)

Thank you for this post; I think I will learn a lot from it as well.

YES, I do that!!

When I receive report from ED onto the floor, I like to know what they came in with and what was done for them. Like what medications you gave, what tests/labs they did and what were the results, and why they're being admitted upstairs. Is it for observation purposes, or are the doctors planning to do a procedure or run more tests?

I like to know their orientation and whether they ambulate. And of course primary history and surgical history if it's possible.

And most definitely if they're on important medications, like an amiodarone or heparin drip. Or librium tapering, and where you're at in the librium tapering. If they're on telemetry, what their rhythm has been. Like if they run NSR, but had several beats of asymptomatic vtach, are the doctors aware and if there's orders to call only if they run say more than 20 beats the next time. Code status is soooo important. I don't expect much in terms of skin assessment from the ED.

Oh one biggie is if security took any of their belongings! Belongings ALWAYS somehow get lost in the ED or en route to the floors and it can be a big pain to track down missing glasses or a cane.

barcode120x, ADN, BSN, RN

Specializes in Telemetry. Has 5 years experience.

Chief complaint/reason for admission, any procedures done in the ER, any specific things done to the patient for a specific reason, and a super quick assessment is all I need. Everything else can be figured out when the patient is on the floor and my own assessment can be done. I learned that hounding the ER nurse for info on the patient usually gets me nowhere. I might as well wait until the patient comes up and figure out what's going on myself.