Do you look up your patient history before taking care of them

[Blackheartednurse]

I'm a new struggling nurse and I noticed that some of the nurses come in 30 minutes before the shift to look up their pt info in the charts,while some just come in right on the clock and proceed to their tasks..I learning to multask in addition to trying to get the basic downs (like dilute meds,starting IV,changing dressing,working with IV pumps,trascribing and reading doctors orders) I find it so hard to just come in right on time and take care of the patients right away (5 minutes is not enough for me to just quickly glance at the chart) I need at least 15-20 minutes to get familarize with my patients medical issues and read doctors notes,but by the time I come in it is time to assess and distribute the meds and go on with the usual nursing tasks...like let me give you an example that happend on my shift that made me realize how important it is to know throughly your patient chart...We had a pt complaining of weakness in her L leg,so neuro consult was notify,they wanted MRI done,but I read in her history that she had a stent put in recently,I notified my preceptor and she said she knew that and she will call the MRI department and let them know..so the MRI people decided it was to early for our patient to have the MRI (usually you have to wait for 4-6 weeks after the stent is put in) so we let the doc know and he ordered the CT contrast..so I'm thinking to myself,what about if I was on my own and didnt read the chart throughly and send patient to MRI,I ,mean this lady's history was long,so my question to you is do you read you chart throughly,do you come in to your work earlier to look up patient info,how early,will I get faster at reading charts (granted I survive orientation),did you find helpful to read chart when you were a new nurse? Gosh nowonder hospitals like to put new nurses on nights,I will working on evening though!

[TigerGalLE, BSN, RN]

Do you not get any of your patient's history during report?

[Virgo_RN, BSN, RN]

We have to fill out a questionnaire on every patient prior to an MRI. The MRI department will not take them without that questionnaire. So in this instance, it wouldn't have made a difference were you at my facility.

To answer your question though, some of the floor nurses at my facility make a practice of coming in 15 minutes early to get their assignment, find a quiet corner, and look up their patients' info before getting report from the offgoing nurse. Others simply tell the offgoing nurse that they need 10-15 minutes to fill out their brain sheet prior to taking report. Since shift overlap is 30 minutes, and shift report is supposed to only take a few minutes per patient, this is reasonable.

When I worked the floor, I did not feel comfortable walking into any patient room prior to having looked at their H&P and reviewed their chart, for two major reasons. The main reason being that if I didn't know anything about them, then how would I know which assessment findings would be expected, and which ones would be concerning? For example, if I already knew a person had a history of CVA with residual deficits, then the right facial droop I'm noticing won't come as a surprise, and I won't have to go look up their medical history to find out if it's their baseline, since I had already looked it up (I found I couldn't always rely on the offgoing nurse's report to tell me everything I needed to know; if I didn't look it up for myself, then I would not take another nurse's word as gospel; I have been burned way too many times by bad information in report).

The second reason is too many times, walking in the door, of being met with a barrage of questions by family members hungry for any information they can possibly get. If I had already perused the chart, then I could tell them that Dr. Soandso had rounded that day, and that s/he had written that s/he is anticipating discharge in the next day or two, or that Dr. Heartyheart had put in two stents and would be up in the next couple of hours after he's finished in the cath lab. I really prefer not to have to say "I don't know", then have to go look it up to appease family members when I could be doing something else with my time, like finishing my assessments and charting them, perhaps.

In the ED, it's a completely different animal. Sometimes I do have a moment to sit down and look at a patient's medical history, but often it is not relevant to why they are there at that moment, and if it is relevant, I just don't have the time to look it up. I have to rely on what I am seeing at that moment, what the patient is telling me, what the family members are telling me, and that the doctor has looked up their medical history and knows what they need to know (our docs always look up the patient's medical history before seeing them, unless it's a resuscitation or something immediate like that).

[BookNerdRN]

I work on a surgical floor and typically most of the nurses come in about 20 minutes early to looks at their patient's charts/history etc. I've been an RN for about a year now and I like that. It gives me a more well-rounded view of the patient's overall health and history, not just the reason why they are on my floor. This time also gives me a chance to look up labs and treatments that need to be done on my shift, any funky orders or if they have chest tubes, NGs, drains, etc, and what meds I'll be passing. I think it's very helpful. Even our nurses who have been working for 20+ years come in early to do the same. I think the expectation is that we know our patient's background and the verbal report we get from offgoing nurses consists of the facts we need from the prior shift (IV credits, I and O, problems, etc.)

[Jules A, MSN]

We use a MRI checklist that is done by the physician and verified by the MRI dept.

[kathy313]

I usually tried to check the H&P, it helped me get a better view of the patient. Even when I worked at the nursing home, I would pull a chart or two a night and go over them.

[Ahhphoey]

I read my patients' H&P's before report, in particular the PMH and reason for hospitalization. Honestly, though, I usually get to work right on time or just a few minutes early. I usually pull up the H&P on the computer and glance through with the off-going nurse during report (or on my own if the nurse is still finishing up something). The patients history is part of report though, so I'm really just verifying I have a complete history. I work in ICU, though, and doing this on 2 patients is a lot easier and quicker than doing it on 5-7, so I can see why your coworkers may come in early to prepare.

Its just gonna take some time to figure out your routine and what works best for you. I'm sure you'll do just fine.

[Blackheartednurse]

Do you not get any of your patient's history during report?

We do a very quick report,outside of each patient room we hava a shelf where that we keep charts and a previous report sheet.

[leslie :-D]

i'll tell you, when i was in nsg school on various rotations, i'd have (experienced) nurses giving me all sorts of advice.

i remember one distinctly telling me not to sweat it, since all we do is "follow doctor's orders".

through all these suggestions, i already knew what i deemed wise.

the rest, i blew off.

that said, i make it point to arrive early.

i just cannot imagine giving good nsg care w/o knowing anything about my pts.

and, will not depend on report as the final word.

leslie

[Blackheartednurse]

We use a MRI checklist that is done by the physician and verified by the MRI dept.

Unfortunately I work in a teaching hospital and the nurses are responsible for making sure all the consent are signed,we fill out pre-procedure checklists,pre-test checklists. It is expected of us.

[Virgo_RN, BSN, RN]

i'll tell you, when i was in nsg school on various rotations, i'd have (experienced) nurses giving me all sorts of advice.

i remember one distinctly telling me not to sweat it, since all we do is "follow doctor's orders".

through all these suggestions, i already knew what i deemed wise.

the rest, i blew off.

that said, i make it point to arrive early.

i just cannot imagine giving good nsg care w/o knowing anything about my pts.

and, will not depend on report as the final word.

leslie

Agree with this, except that I did not make it a practice to arrive early. I worked for free way too much as it was, in the form of missed breaks and having to stay late to finish charting. I was not about to donate any more of my time. What I often did was ask for a few minutes to get my brain sheet together before taking report, or if the offgoing nurse was really antsy to give report and go, I'd just take report, then finish collecting my information. I never set foot in a room until I had done this, unless there was a matter of urgency to attend to, like once when a patient was having a contrast reaction right at shift change. As long as everyone is stable, they can wait a few minutes for me to collect my info prior to coming in to assess.

[vivacious1healer]

Very few RNs I work with come in early to review their patient's chart/history. Most seem to get their bedside report with the off going RN, and then go back to the computer to review the chart. In my experience, I have found the first 2-3 hours of the night shift to be busy, so I know I will be pressed for time, if I don't do this ahead of time.

I try to as I have a way of doing things that helps to keep me organized...printing out the MAR sheet(all documentation/orders/mar are computerized) and writing on it: Dx. , allergies, pmhx, MD, neuro, resp, cardiovascular(b/p or tele/rhythm) diet/GI, GU, activity level. Then reviewing the initial H&P, and the most recent progress note, and review orders and lab results. More than once the computers have crashed/frozen up and had no access....one time for almost 8 hours! This way I have all info, and can still access the pyxis for meds, since I know what medication/when it should be given. OR if a patient codes, I can rattle off all the information from my sheet if I can't access the information from the computer.

You will find a way that works best for you, and make a habit of it.