Best way to give report...

Specialties Ob/Gyn

Published

Specializes in Birth center, LDRP, L&D, PP, nursing education.

I know how to give report for a labor pt, and for a PP pt. I find myself very disorganized when giving PP report from a recently delivered pt. My brain feels fried from caring for the pt and charting like crazy after a delivery!

I made myself a cheat sheet containing Dr, Pt Name, Room, DOB, Support person, Allergies, GPTAL, EDC, Blood type (Rhogam?), GBS, HepB, Rubella, Hx (PPD/GDM/PIH), Labs, IV site, Nubain (time & pain scale), Epidural (Dr., Time, Test Dose), SROM/AROM time, pertinent I&O (LR/Emesis/Urine/EBL).

Am I missing anything?

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Does your facility have a pocket "cheat sheet" developed for you to take notes on for each pt during the shift? If not, you might want to design one - create boxes labeled with each of the items you mentioned so you can fill in Y/N, lab values, etc. Then during report, you can just follow you cheat sheets.

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Specializes in Community, OB, Nursery.

A couple other ideas, feel free to take them or leave them :)

time of delivery

type of delivery - SVD/instrument/c-section

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Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

For a PP pt, I wouldn't give ROM time unless it would affect her care (such as PROM that resulted in chorio). I really like to be succinct in report, and I dislike giving irrelevant info. What I would add to that:

Type of delivery

Status of perineum (lac - degree? repaired? edema? have you shown her how to use ice/tucks/dermoplast)

Last time bladder emptied

Status of legs post-epidural (is she ambulatory yet? Independently or with assist?)

Any PP pain meds received

Has she had a successful breastfeed yet?

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urine drug screen, social service consult - we include these for every pt in our facility since they are so commonly needed with them

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Does your facility use the SBAR form for reporting? There's L&D specific ones that might be helpful to you.

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Specializes in Birth center, LDRP, L&D, PP, nursing education.

Yes we do!!! This would be so helpful.

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Can you share the document? I think it may be useful for me as well... I can also be better organize when giving report. =) thanks!

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Specializes in L&D.
Does your facility use the SBAR form for reporting? There's L&D specific ones that might be helpful to you.

would love to see folks share some of their L&D report sheets, SBAR or otherwise!

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