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!

[Argo]

Speed and being thorough will come with time. Take it easy on yourself and go a little slower so you don't mess up, with experience comes speed. Patients that have an immediate need I would o through theh&p first thing, the other patients I would round on with chart in hand and asked them some questions while I'm reading through. Working in OR I ha to get real fast, real quick with scanning the chart. Its scary how many doctor's don't do thorough preops, patients will die real fast with one missed detail.

[NurseAdida]

For MRI there is an MRI check list that has to be filled out by the nurse or some places patients do it so that helps. I always look up history when taking report. I cannot come to work early to look up things that I can look up during report....I am a good multi tasker I guess.

[whichone'spink, BSN, RN]

I have to, as long as I am in school writing care plans.

[KMRNOCN]

Maybe you could develop a report sheet for yourself that includes the questions you want to know and run them off on the copy machine. Admitting dx, changes, dx tests, bx results, labs, etc. You could be right on spot with your questions, get a basic history, assess your patient and tasks to be done then check the chart. Our hospital has a scut sheet that list everything and a report sheet that is updated each shift. I can't say things aren's missed, I work outpatient oncology, but even if your facility doesn't have what you need you can improvise. You might start something new. Back in my ICU days we all went in early and reviewed, but we can't clock in till 5 minutes before and it's frowned upon if you forget to clock in so I think the coming in early has gone by the wayside. Sounds like your own your way realizing that the chart holds the answers.

[mappers]

I used to come in about 20 minutes early to review stuff, until last week. Signs appeared on all the phones (where we clock in) that said "No early clock-ins". So now I don't. I don't work for free. I clock in the allowed 5 minutes early, review my labs and Kardexes before getting report. Then I'll look at meds, etc. If I have time, I review H & P's. We get some history in report but some nurses are much better at giving report than others KWIM.

[Tweety, BSN, RN]

I don't come in early and work for free, the 12 hours that turn into 14 hours is long enough, and I don't read the chart prior to going to see the patient. After report I hit the road and start seeing patients.

Our nurse to nurse reports should contain a the patient's history and pertinent information, and this works relatively well for me. I work in med-surg. Then I proceed with a head-to-toe assessment and basic care, which is pretty much the same regardless of history. Relatively early into the shift I'll try to get to the chart for a review.

It does happen sometimes that information pops up and I say "gee I wished I'd known that".

[MERRYWIDOW46]

I am there 10-15 minutes early to get organized. I float to all areas of the hospital so every day is different. I get report (brief history is included), review last VS...if some are low look at previous for trend, check orders and labs, review meds prior to making quick rounds. First round are u breathing or in pain. Next round, insulins, pain meds, assessments. Next 1000 meds and so on. We use pre-procedure check list for MRI so no problem with missed implants. I work at a major university teaching hospital. Sometimes the best organization plan has to be altered because of an emergent or urgent change in a patient. If I am tied up for a long period of time I get the charge nurse to check patients I have not seen yet.

[Blackheartednurse]

I have to, as long as I am in school writing care plans.

You have to? That means you dont want to? I mean you should be aware that you will always have to look up their history throughout your entire nursing career.

[Blackheartednurse]

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.

Yeah when we came in we arleady have an MAR ready by the patient room.

[newnurse66]

I have never come in early to read their history, management would not approve that. But after I received report, I would go and read the first note written after admission, as I found this to have the most complete history including the previous medications taken at home, which helped during med pass when patients wanted to know which medication was for what, and I could explain "oh you took this at home called "ex" and this is similar just a different brand that the hospital uses", patients found this extremely helpful . . .the next note I read was the last note by the MD, this helped determine what new things were going on or if the patient was going to be discharged, helped plan my day much better. I found that if I didn't have all this information, I would have a hard time answering the pt's questions. This also helped in my time management, because the morning med pass would take the longest and it was nice to answer their questions at the same time, instead of trying to come back and looking like I didn't know their history or what was currently going on with them.

[cherrybreeze, ADN, RN]

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.

Of course the nurses are responsible for the consents, checklists, etc. The point, I believe, was that there IS a checklist...yes, you're filling it out, but in the course of it, you're finding out anything that would potentially be a reason not to have the scan done. The form is then faxed to the MRI dept, who reviews it and determines if doing an MRI is safe.

What kinds of printouts does everyone receive on their patients? Our profiles contain the history, it gets typed in along with any other pertinent info (if they've had multiple procedures while hospitalized, we'll put what and when, etc) so it's not totally necessary to review the chart first thing. The meds are all listed on it, therapy orders, IV sites and dates placed, etc. I'll review charts throughout the shift when I have time, but the info that I need to know, including the PMH, is all there at a glance.

[traumalover, RN]

I work in a fairly large hospital with a variety of nurses and very very few come in early. Pretty much every report I get and give, PMH is included. Such as this is so and so. They have a PMH of this, this, this, this....they are here for...etc,. Of course I work ICU so we only have 2 patients! Very thorough report, still I would think most nurses ask for pmh during report and every nurse should know their pt's pmh.. This is crucial-at a rapid response or code you will be asked this if you're the primary nurse, and we can't properly treat a pt if we have no clue what may have precipitated this event. PMH, even an extensive one, shouldn't take that long to give in nurse to nurse report!