I work as a Charge RN on a med-surg unit and I'm looking to see what others do for their shift reports/summaries. Currently, we have a template which is then handwritten for each patient that includes Name, Age, Sex, MD, Allergies, PMHx/PSHx, Code Status, Isolation, CMO (comfort care), DPOA status, Recent tests/procedures, IV access/fluids, abx/steroids, diet, activity, abnormal labs, Anticoagulation, PCA/PCEA/Pain/Anxiety, Dialysis access/schedule/fluid removed, etc. The Charge RN gets updates from the other RNs and writes them per shift, and then uses this for daily rounds to provide a snapshot of the previous shifts, and identify any barriers to discharge etc.
I'm looking to see what everyone else uses, and perhaps for a copy of the report sheet that ya'll have as well as any ideas. Any info is appreciated!
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Hi All,
I work as a Charge RN on a med-surg unit and I'm looking to see what others do for their shift reports/summaries. Currently, we have a template which is then handwritten for each patient that includes Name, Age, Sex, MD, Allergies, PMHx/PSHx, Code Status, Isolation, CMO (comfort care), DPOA status, Recent tests/procedures, IV access/fluids, abx/steroids, diet, activity, abnormal labs, Anticoagulation, PCA/PCEA/Pain/Anxiety, Dialysis access/schedule/fluid removed, etc. The Charge RN gets updates from the other RNs and writes them per shift, and then uses this for daily rounds to provide a snapshot of the previous shifts, and identify any barriers to discharge etc.
I'm looking to see what everyone else uses, and perhaps for a copy of the report sheet that ya'll have as well as any ideas. Any info is appreciated!