Nurse to Nurse report: The purpose is to give them a baseline in which to start their shift. The printout posted by Shook is similar to what I use. Keep it simple.
When you get report, what information does the nurse give to you? If I'm going through the systems, it sounds something like this:
PMH: Diabetes, Hypertension, GERD, Smoker 1 ppd. Hysterectomy, Appy, Chole.
DX: MVC (motor vehicle crash) on 6/22, restrained. Compound fracture of L femur, in external fixation.
Resp: Room air. Requires 2L NC at night. Diminished in bases.
Cardiac: Normal Sinus Rhythm, occasionally has PVCs. Hypertensive at baseline with systolic averaging in the 140's. Upper extremities have good pulses. Weak pulses in feet. Tmax was 100.2 last night, but temp came down with tylenol.
GI/GU: Consistent carb diet, NPO at midnight. No BM yet. Foley in place. Urine output adequate.
Neuro: Glasgow of 13. Patient opens eyes to speech and is confused to time and place. PERRLA at a 3 to 3.5
Skin: Left hip is ecchymotic. Left leg in external fixation, bandages clean and dry. Scattered abrasions on both arms from airbag deployment. Turn Q2
IV: 20g L arm, 22 g R hand.
Fluids: LR @ 75
Tubes/Dressings: JP drain at L knee. Empty Q6 hours. Serosanguineous output. Turn Q2.
Labs/BS: ACHS fingersticks. High as 306 today, covered everytime and they just increased her Lantus.
Issues: Oxy Q4 and IV morphine for breakthrough pain. Pain has been at a 4. Tylenol for fever. Patient's family at bedside. Watch out for sister, she challenges everything you do so be prepared to explain medications and why you are turning the patient. Husband at bedside and will spend the night.
A good report will take anywhere from 4-7 minutes, less if they had the patient before.
If you're unsure what someone else wants, just ask. You don't have to magically guess what's needed, and as you ask you'll start to learn what is needed from whom.
Also, if you get one of those nurses who has to know specifics, I just tell them "I don't know off the top of my head, but it is charted."