ED to Psych Report

balbiRN · Mar 22, 2016

This is what I personally think is important in a good report and depending if I receive report from the ED nurse or a psych triage nurse; name, age, gender, MR# (if they're being transferred from another facility and they're not in our system), reason why they came in, latest vitals, abnormal labs, urine drug screen, alcohol level, meds recently given, over-all appearance, gait, calm and cooperative or do I need to prepare for a crisis intervention.

audreysmagic, RN · Mar 31, 2016

I always want to know at minimum - age, gender, reason for admission, diagnosis, how they've been behaviorally in the ER, any meds given in the ER and why, last set of vitals, any pertinent abnormal labs (I don't really care about a RBC count that's high by 0.1 but I DO very much care about a HGB of 7.9, for a random example), significant medical history (not "they had chicken pox at age 5" when the patient is 32), AxO status, ambulation, allergies, UDS results, home meds, and last set of vitals. Obviously, if they're an OD I'd want pertinent information to that, too. If you have the time or knowledge of the situation, I'd love to know any psychosocial stuff you happen to know, how they've been interacting with any visitors/family members, etc, but that's me. I work in a freestanding psych facility, though, so keep in mind, I'm usually asking for more information because the transfer paperwork that gets sent over is usually a bare minimum to see if the patient is appropriate for my hospital and I don't have access to the patient's chart. If I were psych in a medical hospital, there might indeed be fewer details I was concerned with. (Also, keep in mind, if a nurse from a freestanding facility starts grilling you on medical details, it's not that we don't trust you, but we also don't have an ER we can ship the patient to/RRT if something isn't caught and a patient goes south. Sadly, a lot of medical hospitals tend to forget that the mentally ill can also have very real physical concerns.)

Also, if you have a patient who is, shall we say, less than calm and cooperative, considering a PRN for them (if appropriate, obviously) prior to transfer will make things SO much easier for the receiving nurse. Especially if it's an inter-facility transfer. I've had some patients go full wolverine on me within seconds of arriving and, according to the previous facility's records, they were agitated upon discharge but hadn't been medicated in the last 12 hours...