Documentation

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Hello Im a first year nursing student and I wanted to know if you have any advice and how you document the verbal hand off from shifts?

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Specializes in ED.

I just chart report received, put the nurse's name that gave report, then get a quick visual of my patient and chart safety measures in place.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

do you mean write the information down from report?

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"Document" is generally taken to mean "write down in the chart." All you need to say in that case is nicely summarized by Racer15 above.

If you mean, what do you need to write down from report so you have it to work with, my colleague Esme has some wonderful brains sheets that would do you nicely and help you organize your thoughts for the shift.

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Specializes in Critical Care, Education.

Follow the organization's policy.

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Just chart: "verbal report recieved from Nurse Blah Blah." Everything from that verbal report should have been documented in the chart already by the nurse who gave you report. If she did not document then you cannot back document for her. You can note in the chart that Nurse Blah Blah said "Yadda yadda." But that is about it.

If you are talking about writing down the info obtained from shift report for youself you can use this sheet. I use this one for myself. On the back I write down any scheduled xrays, labs, or special test and anything else of value. I also carry a small notebook to write things down in. Remember to shred this at the end of the day to protect patient privacy.

Rm #_____ Name______________ Age:_____ V/S q____h Neuro q_____h FSBS___________

[TABLE=class: MsoNormalTable, align: right]

[TR]

[TD=width: 58] ]

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[TD=width: 64] ]Temp

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[TD=width: 44] ]HR

[/TD]

[TD=width: 43] ]RR

[/TD]

[TD=width: 42] ]O2

[/TD]

[TD=width: 52] ]Pain

[/TD]

[TD=width: 64] ]FSBS

[/TD]

[/TR]

[TR]

[TD=width: 58] ]HX

[/TD]

[TD=width: 64] ]

[/TD]

[TD=width: 44] ]

[/TD]

[TD=width: 43] ]

[/TD]

[TD=width: 42] ]

[/TD]

[TD=width: 52] ]

[/TD]

[TD=width: 64] ]

[/TD]

[/TR]

[TR]

[TD=width: 58] ]0800

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[TD=width: 42] ]

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[TD=width: 52] ]

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[TD=width: 64] ]

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[TR]

[TD=width: 58] ]1200

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[TD=width: 44] ]

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[TD=width: 43] ]

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[TD=width: 42] ]

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[TD=width: 52] ]

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[TD=width: 64] ]

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[/TR]

[TR]

[TD=width: 58] ]1600

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[TD=width: 64] ]

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[TD=width: 44] ]

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[TD=width: 43] ]

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[TD=width: 42] ]

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[TD=width: 64] ]

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[/TR]

[TR]

[TD=width: 367, colspan: 7] ]F/U à] call MD meds chart

]

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[/TABLE]

MD:________________________

Admitted:________ DX:_____________________

PMH:____________________________________

Allergies:_________________________________

IV #_____ L / R _______W/_________

#_____ L / R _______W/_________ Activity:

NEURO: A & O x ____ Follow Commands Y N Labs/TX:

Speech: C S A MAE Y N RUE RLE ULE LLE

Pupils R/l____mm B /S/ NR L/l____mm B /S/ NR Notes:

Cardio Tele Skin/Wounds

Resp/O2

Diet Last BM GU Foley VOO

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

If you need a good brain sheet.......here are a few.

doc.gif mtpmedsurg.doc

doc.gif 1 patient float.doc‎

doc.gif 5 pt. shift.doc‎

doc.gif finalgraduateshiftreport.doc‎

doc.gif horshiftsheet.doc‎

doc.gif report sheet.doc‎

doc.gif day sheet 2 doc.doc

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