End of Shift Report

JentheRN05, RN · Aug 22, 2005

Thanks for all the replies!! That helps a lot!

Where I work, I was referred to as Windy for a couple of weeks. Where I work, they want you to give the info ONLY off the Kardex, anything other than that you can give them after the taped report, after they come out of the room. So that's what I do anymore. My shift thanks me for it. That way we all get out sooner. I was trying to err on the side of caution, but found that it is just as efficient to update afterword. Like, the patient prefers her meds crushed for easier swallowing. There's no note of any hint of problem with the patient swallowing, but after 1 dose of meds in solid form, and her complaints of feeling nauseas I tried the crushed method (always make sure the meds can be crushed. most extended relief can't be), and the two that couldn't be crushed slide them in with the applesauce, goes down much easier. I passed that on and everything went fine (she was a supposedly difficult patient prior to my discovery)

fireflyLPN · Aug 22, 2005

Ok... In my facility, we don't use the taped report. We are just given the Kardexes, and given 20 minutes to review them. Then we go out and find the nurses who had our pt's, and get report from them (which is supposed to take 10 minutes or less). I don't like repeating the things that are given on the Kardex, but I do like reiterating certain things. Like, I repeat the activity level because I know that at least one of my pt's will want to get up when I first go in there, and the activity level isn't something I usually remember from the Kardex (for whatever reason). So if the nurse is getting the Kardex, and getting conceivably enough time to read it, should I really repeat all that info... 'know what I mean

Thanks!!

dinkymouse · Aug 22, 2005

I get so frustrated by report in our LTC. It is on a written board with some verbal thrown in. Unfortunately some doesn't get written down or passed to the next shift. In the past week I found 4 patients who had diarrhea of and on for over a month. It was info given by aides to the nurses who didn't write it down or pass it along. Our cna's aren't allowed to chart anything so if the nurse doesn't pass it on no one knows it. 1 of those patients had an order for lomotil that no one had given her. :madface: The other 3 had nothing for it and one was still getting a laxative qd. Someone could be next to death and we might still not know it. Sometimes we have to work a wing that we seldom do and nothing is on the sheet. I don't have time to look at 40 charts to see whats going on. I have my own report sheet and I give the pertinent info although I do say if they've had visitors or specific non medical concerns. It is such a pain walking into a room and finding your patient with an O2 sat of 84 after a neb tx, t 101 and nothing has been charted but the next day you hear from the nurse that had been on duty-"He's been having problems for a few days." GRRRRRRR

hjvmbm · Aug 22, 2005

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.

In the 2 years of nursing, I have found that every nurse is different in their expectations of report... I am particular in what I would like to hear from the reporting nurse.. I always want to know the basics (history, orders, lab work, etc.) and also like the things that are not in the medical chart (iv site, their personality, what type of things to expect, how they take medications, etc.).. I have been fortunate that on my unit everyone pretty much loosk for the same things so we all know what to tell each other and what to leave out.

Daytonite, BSN, RN · Aug 23, 2005

Other than the patient's name and maybe their diagnosis I don't repeat all the orders. They can get them from the Kardex themselves. I report any treatments I did on a patient and any notable observations about a wound. If the patient has had abnormal labwork or some sort or x-ray or important test or procedure by a doctor I report that along with any information they need to know and pass on. I reported any special instructions from a doctor or a nurse specialist that didn't get written as orders. I reported any calls I made to a physician that resulted in a new medication order. Any incidents involving the patient are reported. Anything that needs follow-up is reported (ie. a call out to a doctor for a medication order or to report a change in a patient's condition). It sounds like the things you are reporting are items the oncoming shift can find for themselves, so there is no need to report them again. One exception I would make is if a patient is NPO for a specific test or surgery or there is some special prep that needs to be done by their shift (just to give them a heads up). It's OK to say that the patient had an uneventful day and nothing new went on. . .go on to the next patient. Think about what you think the shift you are reporting to should report to their oncoming nurses. Things like a fall, or the patient gets confused and tries to pull out tubes are important to report.

I used to come in early just to have a chance to go through my patient's Kardex's to pick up lab, x-ray, treatments, NPOs, surgeries, preps for procedures. So, when you come in to give report I already know that information. I want to know stuff that's not on the Kardex or may not have had to be charted but affected the patient's care.

TracyB,RN, RN · Aug 27, 2005

Our Kardex's don't tell us diddly squat... they are often several days out of date, don't have activity, diet, etc..

In report I give name, age, attending, admitting dx, diet, meds crushed, foley, last BM, fluids running & where, O2, activity level & transfer status, meds held, last blood glucose & any insulin given, any prn's & times I gave them (so I can have an idea when pt will be asking for next dose & of course, I always check my MARS before giving, anyway), & anything that may be pending for oncoming shift ie: waiting for a lab draw, return call from MD, or something like that... Sometimes it is pertinent info if so & so's sister visited. Family dynamics can be strange & if my pt is p/o'd or weepy, I like to know why.

chelojelo · Aug 27, 2005

where i work we tape report. I like the report to be a little more detailed, as a lot of times i'm off work for 4 days at a time, and with 50+ pts, i don't have time to dig thru charts. Recording report has it's pros and cons. On the upside, if you're the nurse going off duty, it saves you time. On the downside, if you're the nurse coming on, you don't have the opportunity to ask the nurse who left any questions. I like to hear about their personality, demands of their families (a big one), things like that on a new admit if i haven't met the pt before, because these are things that are usually not in the chart. Things i don't like to hear are their diet orders, how they take their meds (we usually note this near the bottom of their mar), allergies, and other things that can be easily found on my own.

estrogen · Aug 27, 2005

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.

I find it most important to give a brief history. What's wrong with them, what's being done about it. ...That info allways helped me to have a somewhat accurate picture of what to expect.

stidget99 · Aug 27, 2005

My typical report:

Mrs. Jane Doe is an 84yo pt of Dr. Harris in w/ right hip fx due to fall at home this morning. Scheduled for a ORIF tomorrow once PT/INR are back in order. She's been on coumadin at home. Vit K given today. Consents and site verification are done/not done. 5# bucks txn in place. 1st of 2 units of PRBCs up and running. VSS since admission and start of blood.

She has a hx of COPD, DM, OA. (I don't mention the TAH she had 30 yrs ago).

She has NS at KVO in the RFA w/ #20g...

Currently on clr liq diet but NPO after MN...

O2 at 2L/min via NC...

Nebs q4 and q2prn

16fr foley placed in ER draining adequate amts of clear yellow urine. (If a pt gets up to BSC I always address safety issues re: # needed to safely transfer)...

A&O to self only. Family is/is not involved in basic cares/supervision...

Takes meds crushed in apple sauce...

Accu checks AC/HS---values have been slightly high...had to slide her twice...

DNR if applicable....

Did I miss anything? Any questions???

That is typically my report. Try to take less than ~3mins/pt. Rarely report last prn given accept if they will be calling for it in the first hour on the floor.

bellcollector · Aug 27, 2005

The last facility I worked at the nurses were good for completely ignoring you during report and never writing down a thing you said. Then when they would miss something or fail to do something they were good for saying I didn't recieve that in report. So a friend and I came up with a report sheet it had each pts name on it with space to write for each one. We had blood sugar typed in then a space to record it same with insulin and amount given. We included pertinent info like gait, how meds taken etc.... in typed portion. Then in the space by each pt we would use black ink to write down what we recieved in report and red ink for what happened on our shift. At the end of the shift we would initial and date the sheet make 3 copies, give report verbally and then hand the sheet to the oncoming nurse and put another copy in the unit managers box and kept the last copy for our records. Those we kept in a special personal file on site. Amazingly they were no longer able to say we didn't get that in report. I agree with erroring on the side of too much info. We also would often ask oncoming what info they wanted and give just that verbally but then still hand them the sheet for ready reference. Worked for us. Bell

estrogen · Aug 27, 2005

My typical report:
Mrs. Jane Doe is an 84yo pt of Dr. Harris in w/ right hip fx due to fall at home this morning. Scheduled for a ORIF tomorrow once PT/INR are back in order. She's been on coumadin at home. Vit K given today. Consents and site verification are done/not done. 5# bucks txn in place. 1st of 2 units of PRBCs up and running. VSS since admission and start of blood.
She has a hx of COPD, DM, OA. (I don't mention the TAH she had 30 yrs ago).
She has NS at KVO in the RFA w/ #20g...
Currently on clr liq diet but NPO after MN...
O2 at 2L/min via NC...
Nebs q4 and q2prn
16fr foley placed in ER draining adequate amts of clear yellow urine. (If a pt gets up to BSC I always address safety issues re: # needed to safely transfer)...
A&O to self only. Family is/is not involved in basic cares/supervision...
Takes meds crushed in apple sauce...
Accu checks AC/HS---values have been slightly high...had to slide her twice...
DNR if applicable....
Did I miss anything? Any questions???
That is typically my report. Try to take less than ~3mins/pt. Rarely report last prn given accept if they will be calling for it in the first hour on the floor.

Perfect. That's all I'd need to know. Can't stand when they go on and on and on about irrelevant tnings.

mak2 · Aug 28, 2005

I have always thought report was an excuse to sit for 30 mins. I agree with you your report is concise and all information needed is there. After I take over a patient all I want to know is what I have to do before my assessment and during the period it takes me to research my patient. You could tell me anything and it is still my responsiblity to "know" my pt.