What are your most important pieces of information when giving/getting report? - page 3

I'm a new grad and have been comparing report techniques from the nurses I work with. Some are to the point, some go on with much information. So, can anyone give me the top basic information for... Read More

  1. by   RN-PA
    I work Med/Surg and I prefer MORE rather than less information on my patients. I work part-time and so rarely get the same patients twice, so I'm starting from scratch, so to speak, most shifts. We read a computer generated patient profile for reports, and I write and frequently read along on the profile while I'm listening to report. If you don't tell me the person's allergies or medical history, I have to stop the tape to read them on the profile. I will not get the chance to read any Dr.'s progress notes during my shift, so whatever a nurse can tell me about the patients' most significant medical history is helpful (mainly cardiac or diabetes type history-- I don't care if they have skin cancer or a hernia repair in the past, for example).

    To what others have mentioned, I would add that I want to know code status, diet, scheduled tests that haven't been done yet, recent test and lab results (abnormals only for labs), and it's nice to get a warning about a one-time dose med that's due on my shift. IV solutions and credits are always given to the next shift, the type of care the pt. requires (complete, self, heavy-partial), their activity (bedrest, OOB with minimal assistance, for example), VS (how often and any abnormals), Accuchecks (frequency ordered and recent results), O2 settings and sats. It's even helpful if you can tell me such things as whether a particular patient prefers their meds crushed in ice cream or applesauce, or how to approach a confused patient to help me do my job better and save time. Please tell me if there's a certain family member to be aware of if they are extra needy or are gunning for the nursing staff.

    For the assessment, I stick to abnormals and prefer that when receiving report; when I'm giving report, I tend to say "everything else is within normal limits" or is benign after I've gone through the abnormals in the various systems.

    I may be more anal than others (I prefer "detail-oriented" to anal, thank you ), but what you tell me in report is pretty much all I have to go on, so I like to have a pretty good idea of what to expect.
  2. by   NICU_Nurse
    Well, call me "detail-oriented" too, then. One of my peeves is someone who's idea of report is "No changes." or "It's in the chart."

    I work in the NICU, and too often there has been what I feel is pertinent information that is just left out for whatever reason. Whether they didn't know or they didn't bother, either way, I'd like a fairly thorough report. If we've both been working with the same baby for the last three days, obviously I don't need to hear maternal history EVERY single time we meet up, but if it's been a while since I/you had the baby, or if there were major changes that day, or something new that you found out about it, please let me know! Someone coming up to me to ask if the baby has been showing withdrawal symptoms and someone forgot to mention that mom was a raging heroin addict not only makes me mad but makes me look stupid to boot. Sure, it's all in the chart, and yes, I am fully capable of looking it up, and surely will when I get the opportunity, but too often I am hitting the floor running because there are things to get done, so filling me in on the gist of it will help me tremendously in more ways than one.

    At the very least, I like to go over all medications (are they the same as they were, have the doses/times been changed, did they write a new order for a level, etc.) and tx's, labs that may have been drawn recently (did you send CSF for a culture? Bili because the baby is jaundiced? If so, were they abnormal?), anything abnormal, and a nice summation of the baby's history, especially if I've never worked with him/her before.

    I prefer thorough over not; I'd be more than happy to hear what you have to say about our patient if you'd only take the time to let me know. No, I don't need to know every little thing, but the major issues are a plus.

  3. by   redwinggirlie
    I've adopted the systems approach, but after I follow the patient lists we go by in the morning. These things have slots for VS, labs, diet, activity, IV and comments. I do those first so the techs and RN's can fill in the blanks, then I go on to the systems, treatments due for the day, changes in pt condition, their affect, visitors and any personal information I've discovered about them that affects the way we can care for them. For example, we had a quad who told me if we touch is feet instead of his ankles when we move him, he will go into spasms. That's the stuff I give in report. All of this, mind you, I've borrowed from all of you. Thanks so much. And yes, a detailed report does make a great difference when you haven't had the patient before. I appreciate those reports very much.