I'm a CICU nurse and I've been trying to come up with a more efficient way to accurately and more concisely give report on a patient who's been on the unit for any length of time (i'm talking longer than a couple days).
Specifically, I need tips on tackling the patient's story since admission, not my own assessment or shift changes.
Currently I come in to work an hour early and start looking up my two patients. I start by reading the oldest note...I have to scroll down most of the time...And I try to read EVERY note. Clearly, this takes way too much time but I notice that the reports I get aren't always very detailed and then when it's time for me to give report at and of my shift I realize how many holes their are which leaves me sounding and feeling like I didn't do my job well.
I know that not every bit of information from the patients story is pertinent to their current status but I feel like I always end up leaving out a bit of info that the oncoming nurse ends up asking about. What I think is an obscure detail (like exactly how many bags of NS/PRBC/albumin were given 2 weeks ago or exact times/dates the patient was transferred off or back to the unit) is often the very thing they ask about. I hate having to say "I'm not sure." To a question that specific I usually just summarize that the patient has repeatedly required volume/lytes/pressors etc, and why (such as BP issues/bleeding/resp problems, or patient went to CT/MRI/OR/EP lab last week and important results revealed...etc).
If the patient has only been on the unit for a day or two, it is much easier to go into more detail, not to mention something that happened just a day or two ago is still very much pertinent to the patient's overall status and story. I struggle more with the long-term patients.
Any pro-tips are welcome
I agree with HakunaMatata. Regarding a patient that has been on the unit more than a few days, I give a brief overview of reason for admission, along with significant and/or ongoing events along the way. As for detailed report, I cover my shift, as well as significant events reported to me when I began my shift. If they feel the need to know details of fluid resuscitation and blood products received weeks ago, they can look it up themselves.
And, unless you are on the clock when you do so, stop coming in an hour early and reviewing your patient's record.
Last edit by chare on Jan 18