End of Shift Report

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Hi all,

I am a new nurse working in a hospital. I have tried to do my best when giving report, like giving them the info that is not included in the Kardex, and major things like: diet, level of activity, inform them of any tests scheduled that day, & info on IVs. Judging by some of the looks I have received I am clearly not doing something right... but when I ask "Do you have any questions for me?". I usually get a no... So I would like to hear from some of you experienced nurses what exactly you like to have included when you receive report from the outgoing nurse.

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Hi all,

I am a new nurse working in a hospital. I have tried to do my best when giving report, like giving them the info that is not included in the Kardex, and major things like: diet, level of activity, inform them of any tests scheduled that day, & info on IVs. Judging by some of the looks I have received I am clearly not doing something right... but when I ask "Do you have any questions for me?". I usually get a no... So I would like to hear from some of you experienced nurses what exactly you like to have included when you receive report from the outgoing nurse.

Do not let other nurses dissuade you or change your good habit of giving the best and most thorough report you can. Nothing irritates me more than the incoming nurse showing disrespect by sighing, rolling eyes, ect, when the outgoing nurse is only trying to supply her with the tools needed for effective care and continuity of care. The "annoyed" nurse will be the first one to complain when she realizes she didnt get enough information, or something pertinent failed to get passed on. Be clear and concise, but keep up the good work. I, for one, respect that.

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Specializes in LDRP.

I am fairly new, but when giving report i try to include

name, age, doctor, allergies, dx, admission history (what brought them to hospital), pmh, activity,diet, oxygen, iv's/iv fluids, rhythm (tele floor), dressings, any tubes, labs for today/labs for tomorrow, tests/procedures, etc.

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Hi :) I Work on ICCU step down cardiac telemetry unit......I am a new nurse and I typed up my own report sheet when I started working following an outline of what they do on the unit and modifying it to match my needs.......although this posting does not retain the format of my report sheet I did manage to cut and paste it here for you to see the information.......remember the format of my sheet changed but the basic information that I provide for the report is visible..........hope it helps........getting a good and thorough report is important so that the continuity of care can be provided best..........therefore let me let you know your doing a good job and that is coming from some who is new as well and has an appreciation of nurses who give a thourough report...........I wish you the best on you new career.......take care and be proud of your self

Take care sincerly Angela ses you around

DATE: REPORT SHEET

PATIENT NAME: AGE: SEX: ADMITTED:

DIAGNOSIS: CODE STATUSFC// DNR//DNI ALLERGIES:

COMORBID/HX/PROCEDURES:

HEIGHT

WEIGHT

NEURO:

MENTAL STATUS

LOC

A&OX 1 2 3

ACTIVITY

OOB, BEDREST, AD LIB, COMPLETE CARE, ASSIST, FALL PRECAUTION

GAIT: STEADY /UNSTEADY

ADL'S: USE OF DEVICES, CANE, WALKER, WHEEL CHAIR.

RESTRAINTS: ALL 4 SIDE RAILS, VEST, WRIST , LEGS,

EXTREMITY STRENGTH:

BIL HAND GRASP/UPPER LOWER

VISUAL: PERRLA/VA

EOM FULL/ OR RESTRICTED

HEARING: WNL /HOH

FALL RISK YES OR NOIV DEVICES:

LOCATION/INSERTION DATE/REDNESS

SWELLING/LEAKAGE/PAIN/PATENCY/

TUBING/CHANGES/DRESSINGCHANGES/

BLD OR CLEAN & DRY

AMOUNT INFUSED

OTHER: PICC//CENTRAL LINE//LOCATION:

R OR L HAND//R OR L AC//R OR L FA// # ga.18/20/22

INSERTED:

NS9%

NS .45%

D5%

HEPARIN

CV:TELE PULSE:

NSR//AFIB//AFLUTTER//SB//ST//PACED//VT//VF//PEA//

EKG:

EDEMA:

JVD/PPP/CP/SOB/PALPITATIONS

HOMAN SIGN/PACER WIRES

DAY SHIFT:

TIME: BP HR RR TEMP PO2 PAIN

TIME:

NIGHT SHIFT

TIME: BP HR RR TEMP PO2 PAIN

__________________________________________________________________

TIME:

__________________________________________________________

ORTHOSTATIC BP: LYING////////////////////////SITTING///////////////////////STANDING

TIME:

__________________________________________________________

TIME;

FS:AC/HS OR BID:DAY NIGHT

RESPIRATORY

LUNGS:CLEAR

CLEAR/WHEEZING/CRACKLES/RONCHI/

DIMINISHED/RALES

REGULAR RHYTHMIC 12-24 BPM

AFEBRILE OVER 24 HRS

CONGESTION//COUGH//SPUTUM//PAIN

SOB//USE OF O2: 2LNC

GASTROINTESTINAL

ABDOMIN//SOFT//ENLARGED//OBESEE//DISTENDED/ASCITES//TENDERNESS//N&V

BS PRESENT ALL 4 QUADRANTS

BM 24-48HRS(DATE: )

BLEEDING /QUIACNUTRITION:DIET/NPO

NCS/2GM Na/LOW CHOL/LOW FAT

DIABETIC/REGULAR/SOFT/PUREE

TEXTURED/RENAL

AMOUNT://EAT WELL /POORLY//MEETS STANDARD WEIGHT FOR HEIGHT AGE AND GENDER MEETS CALORIE COUNT

NPO@12M YES OR NO

GENITO-URINARY

CONTINENT//FREGUENCY//URGENCY//DYSURIA//

ANURIC//OLIGURIC//DIAPER//VOIDING//

INCONTINENT

URINE OUTPUT

FOLEY SIZE

INSERTION DATE:

SKIN

SKIN INTACT//WARM/DRY//INTACT//REDNESS

SWELLING//DRAINAGE//TENDERNESS

SIZE OF WOUND//APPEARANCE//LOCATIONPLAN: TEST:CXR/ECHO/CARDIAC CATH/ DOPPLER/ CT/ STRESS TEST

DISCHARGEPLAN:BARRIER/S/NEEDS/CONSULT

HHA HOW MANY HRS AND AGENCY:

MISCELLANOUS:PLAN:

THINGS DONE ON DAY SHIFT

THINGS DONE ON MY SHIFT

THINGS TO DO:

SGOT PT 1ST 2ND 3RD 4TH 5T

CPK

SG INRCKMB

OTHER RESULT: APTTCKMB%

MgTROPONIN

Ca

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I usually go by systems. Start with patient name age diagnosis allergies code status and pmh. Then just a quick system review. I also include the doctors including the consults.

I hate when you are giving report and the person you are talking to doesn't listen to you or starts talking to other people in the room. I got fed up one time with one nurse who frequently looks as if she could care less what you are saying. She started talking to someone else when I was in the middle of a sentence so I got up and left telling her if she had any questions just look at the chart.

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Specializes in LDRP.

ok

DATE: REPORT SHEET

PATIENT NAME: AGE: SEX: ADMITTED:

DIAGNOSIS: CODE STATUS FC// DNR//DNI ALLERGIES:

COMORBID/HX/PROCEDURES:

HEIGHT

WEIGHT

NEURO:

MENTAL STATUS

LOC

A&OX 1 2 3

ACTIVITY

OOB, BEDREST, AD LIB, COMPLETE CARE, ASSIST, FALL PRECAUTION

GAIT: STEADY /UNSTEADY

ADL'S: USE OF DEVICES, CANE, WALKER, WHEEL CHAIR.

RESTRAINTS: ALL 4 SIDE RAILS, VEST, WRIST , LEGS,

EXTREMITY STRENGTH:

BIL HAND GRASP/UPPER LOWER

VISUAL: PERRLA/VA

EOM FULL/ OR RESTRICTED

HEARING: WNL /HOH

FALL RISK YES OR NO IV DEVICES:

LOCATION/INSERTION DATE/REDNESS

SWELLING/LEAKAGE/PAIN/PATENCY/

TUBING/CHANGES/DRESSINGCHANGES/

BLD OR CLEAN & DRY

AMOUNT INFUSED

OTHER: PICC//CENTRAL LINE//LOCATION:

R OR L HAND//R OR L AC//R OR L FA// # ga.18/20/22

INSERTED:

NS9%

NS .45%

D5%

HEPARIN

CV:TELE PULSE:

NSR//AFIB//AFLUTTER//SB//ST//PACED//VT//VF//PEA//

EKG:

EDEMA:

JVD/PPP/CP/SOB/PALPITATIONS

HOMAN SIGN/PACER WIRES

DAY SHIFT:

TIME: BP HR RR TEMP PO2 PAIN

TIME:

NIGHT SHIFT

TIME: BP HR RR TEMP PO2 PAIN

__________________________________________________ ________________

TIME:

__________________________________________________ ________

ORTHOSTATIC BP: LYING////////////////////////SITTING///////////////////////STANDING

TIME:

__________________________________________________ ________

TIME;

FS:AC/HS OR BIDAY NIGHT

RESPIRATORY

LUNGS:CLEAR

CLEAR/WHEEZING/CRACKLES/RONCHI/

DIMINISHED/RALES

REGULAR RHYTHMIC 12-24 BPM

AFEBRILE OVER 24 HRS

CONGESTION//COUGH//SPUTUM//PAIN

SOB//USE OF O2: 2LNC

GASTROINTESTINAL

ABDOMIN//SOFT//ENLARGED//OBESEE//DISTENDED/ASCITES//TENDERNESS//N&V

BS PRESENT ALL 4 QUADRANTS

BM 24-48HRS(DATE: )

BLEEDING /QUIAC NUTRITIONIET/NPO

NCS/2GM Na/LOW CHOL/LOW FAT

DIABETIC/REGULAR/SOFT/PUREE

TEXTURED/RENAL

AMOUNT://EAT WELL /POORLY//MEETS STANDARD WEIGHT FOR HEIGHT AGE AND GENDER MEETS CALORIE COUNT

NPO@12M YES OR NO

GENITO-URINARY

CONTINENT//FREGUENCY//URGENCY//DYSURIA//

ANURIC//OLIGURIC//DIAPER//VOIDING//

INCONTINENT

URINE OUTPUT

FOLEY SIZE

INSERTION DATE:

SKIN

SKIN INTACT//WARM/DRY//INTACT//REDNESS

SWELLING//DRAINAGE//TENDERNESS

SIZE OF WOUND//APPEARANCE//LOCATION PLAN: TEST:CXR/ECHO/CARDIAC CATH/ DOPPLER/ CT/ STRESS TEST

DISCHARGEPLAN:BARRIER/S/NEEDS/CONSULT

HHA HOW MANY HRS AND AGENCY:

MISCELLANOUS: PLAN:

THINGS DONE ON DAY SHIFT

THINGS DONE ON MY SHIFT

THINGS TO DO:

SGOT PT 1ST 2ND 3RD 4TH 5T

CPK

SG INR CKMB

OTHER RESULT: APTT CKMB%

Mg TROPONIN

Ca

good googly moogly! that is a lot!!! how many patients doyou have?? I can't imagine doing that on my 4 patients I have (cardiac surgery PCU). That seems like quite a lot to write down, to all fit on one page, for that matter. And do you report off all of that for each pt at the end of your shift???

i've never seen one that long.

wow!

but if it works for you, go for it!!!

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Specializes in Med/Surg, Geriatrics.

I hate long drawn-out, overly detailed reports. I need:

Name

Diagnosis

PMH only if relevant

Admitting MD

Code status

Mental status

tele rhythm

abnormal VS

report of systems only as they pertain to the diagnosis

mobility issues

social or discharge issues

any special procedures or surgeries planned

keep it brief and to the point. anything else you are supposed to find out on your own anyway. I don't need to know that they have D51/2 infusing into their Lt hand, that they didn't like their meal from the night before, that their daughter visited and stayed for an hour, about your fight with pharmacy to get the meds up, that you gave them Tylenol for a HA, that they asked for 2 blankets, that they had an appendectomy in 1958, that labs or a CXR is scheduled, or allergies(unless unusual).

Conversely, don't expect me to give a life history in report because you want me to give you everything, so you don't have to look. You are supposed to do your own assessment and review the chart. I just need enough to know if there are changes.

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Specializes in Psych.

Wow, you new grads are thorough! Good for you! As last poster wrote, sometimes briefer is better, but hey, I'd rather see a newbie err on the side of caution, wouldn't you? And as for you eye-rollers and rude interupters out there(I've been doing this for 12 yrs and still get it from one in particular, sometimes I just want to b***h-slap him, good thing he is 3x my size, just kidding), shame on you! If a reporter is giving 2 much info, ask them specific ?s. Do the same thing if they are not giving you enough. Come on now, we're all adults, let's just drop the jr. high attitude and treat each other w/respect, kay?

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Specializes in Psych.

Also, I LIKE getting some things in report that could be found on the chart. I don't know about the rest of you, but I often step out of report directly into a madhouse that does not allow me time to look at every individual chart. Remember, this is real life we're dealing with. I make an effort to report all prn (w/times given) meds from my shift. Yes even tylenol, those o.d. s can be potentially fatal, you know.

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Specializes in Med/Surg, Geriatrics.
Also, I LIKE getting some things in report that could be found on the chart. I don't know about the rest of you, but I often step out of report directly into a madhouse that does not allow me time to look at every individual chart. Remember, this is real life we're dealing with. I make an effort to report all prn (w/times given) meds from my shift. Yes even tylenol, those o.d. s can be potentially fatal, you know.

With all due respect kadokin, you should not be giving prn without checking the MAR first, thus eliminating the potential for ods. That is definitely the type of thing you should not be relying on report for. But you're right about treating others with respect, you would not believe the childish and hateful behavior I have encountered before with report.

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Specializes in Psych.
With all due respect kadokin, you should not be giving prn without checking the MAR first, thus eliminating the potential for ods. That is definitely the type of thing you should not be relying on report for. But you're right about treating others with respect, you would not believe the childish and hateful behavior I have encountered before with report.
Right you are, SharonH
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Thanks for all the replies!! That helps a lot!

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