What Do You Want To Hear When Receiving Report?

[rebelwaclause]

When signing off duty and giving report about my assignment to oncoming staff, I usually advise of what I did for the patient during my shift (ie...Meds, dressing's, any treatments or pre-op prep), what was abnormal during my shift (including what physician was contacted and what I did as ordered by that MD), and other pertinent information that would be useful to oncoming staff to know.

I've had nurses go on and on about vital signs from 3 days ago that is not relevant at that point. I've heard long drawn out history about labs from a transfusion days ago (no side effects). I've had a nurse get mad at me for not knowing off the top of my head whether or not patient teaching regarding home abx had been taught to the wife. (The patient was a&ox3. Absolutely no learning barriers. I did advise that the patient did an EXCELLENT return demonstration!)

I find every nurse to be a little different in the information they need to feel comfortably informed. Some want the bare necessities, others want a full head-to-toe assessment.

My question is, what type of report do you need to feel informed? Does the shift you work make a difference in the report you want to hear? What information do you think is unimportant?

Thanks for your feedback.

[dawngloves, BSN, RN]

Please keep it "head to toe"! It makes me NUTS when I get a report that is all over the place! "OK, he is on 21% cannula, his last BM was two days ago, his lungs are clear, last stool was heme negative. " I kid you not!

[Cascadians]

We made up our own form and pass it off to the next shift. Everything documented. Learned how to write really small :chuckle

Getting report isn't always easy. We want to know what has changed, what precautions are necessary, which family members to watch out for, which pts are pulling their IVs, crawling out of bed, escaping the floor, etc

Especially which pt's family members are lunatics and how to curtail their antics ... or if there's a mentally ill pt, how well has their behavior been documented ... CYA kinda stuff ...

[BadBird, BSN, RN]

My report usually goes like this:

Allergies

Code Status

Cardiac Rhythm

VS (any abnormals with treatment rendered during my shift)

Neuro

Pulm

Card

GI (tubefeeds, residuals, if NPO after a certain time)

GU

Skin

IV Sites (central lines, if any are clotted, arterial lines)

IV Fluids (KCL, Mg, Antibiotics given or need to be given)

Plan of care (transfer to step down when bed avail, Social Service consult for placement, family plan to make DNR in am, etc...)

Dr. on call, or Fellow or Resident covering.

Tests pt. went for and outcome (i.e. CT Brain = no bleed, etc.)

Hope this helps. I am probably forgetting something but that is my basic report.

[susanmary]

Looking for QUALITY vs. quantity when receiving report. Plan of care is #1. Also, very important to note type/rate of IV fluids -- as well as approximate # of cc's left in bag -- better yet -- when you are charting I/Os at shift end, if there is less than one-two hours of IV fluids left -- hang a new bag for the next shift.

[aus nurse]

Great thread...very interesting.

I always find out from the oncoming staff if they know the patients. If so, then they don't need all the history, no point in going all thru it again. Any new admissions since their shift, I give a brief history on. Then I just give changes since they last saw the patient and upcoiming orders.

I work all night shifts, so I find that is often the only time when the charts can be thoroughly reviewed, and I can check any thing that has been overlooked and pass that on.

I work float pool in a big place so move around a lot. Each unit has a computer printout that each shift updates and prints for the oncoming shift. It has diagnosis, brief past history, IV's, drains etc, IDC's, diet, mobility, freq of vitals and a box for notes. Sure streamlines what you have to write down. This folds into my pocket, I can add notes to it, then I handover from it in the morning.

[Tweety, BSN, RN]

Originally posted by NancyRN

There was another thread about "bullying during report" that was interesting. I think that some of the questions asked are more to show off than an actual need for information.

My favorite thing is when a nurse is tossing terms at me and I stop her and say "what's that mean?" and she doesn't really know.

I work with a nurse exactly like that. She always asks a million questions that you can't answer. "What was his Potasium Level 16 days ago?".

Let me give my report please, don't interrupt, and then you can ask your questions. I hate when someone asks "what kind IV is he on?" "Well, if you shut up long enough I WAS GOING TO TELL YOU!" hehehe

[mario_ragucci]

I'm not a nurse, but work closely with "them." :-)

Bullying at report? If a RN used a meeting as a plank to begin bullying? There is no excuse for this behavior.

Just know that if I was at report and assessed open-bullying, i would start barking about it right then & there. You see, a bully will one day try it with YOU. The bully is actually a good luck sign because it brings together those that actually take part in the bully's destruction :-)

[deespoohbear]

originally posted by susanmary

if there is less than one-two hours of iv fluids left -- hang a new bag for the next shift.

amen!!

this is one of my all time pet peeves!!!!

[nursedawn67, LPN]

Originally posted by 3rdShiftGuy

I work with a nurse exactly like that. She always asks a million questions that you can't answer. "What was his Potasium Level 16 days ago?".

I think I know that nurse...she works at my facility!!!

[rebelwaclause, ASN, RN]

Originally posted by Sleepyeyes

I like our report system. We have the halls divided and a tape recorder dedicated to each section. You can go give report whenever you have a few minutes, you can talk as fast as you want, and the oncoming shift can just stop the tape and write as much or as little as they want.

Rats Sleepyeyes...I thought this was a great idea too. We tried it, and failed miserably. I'm off at 0730, new staff starts at 0715 (if they are on time...Ooooo...LATE STAFF...ANOTHER THREAD!). There was times up until 0800 that we would have to ask those who have already heard report to come relieve us. I guess their thoughts where they waited until all staff members had arrived before listening, then EVERYONE heard report on everybody, so all would be informed. I loved the tape recorded report, but unfortunately too much overtime was being given, so managers dismissed it.

[rebelwaclause, ASN, RN]

Originally posted by susanmary

Also, very important to note type/rate of IV fluids -- as well as approximate # of cc's left in bag

This is interesting susanmary. I agree, its frustrating when you go to do your assignment assessment and find spit amounts of IVF's left in the bag. (Uhgggg!). But, do I give the approximate amount of fluid left running in a bag during report?

No.

I will report this information if the MD has ordered something like "2 liters then heplock" or something of exact like this. Otherwise, I record and add up my shift I & O's that can be reviewed later.

Sounds like "important report information" is subjective, and no one way of reporting is the "right" way?

[rebelwaclause, ASN, RN]

Originally posted by aus nurse

Each unit has a computer printout that each shift updates and prints for the oncoming shift. It has diagnosis, brief past history, IV's, drains etc, IDC's, diet, mobility, freq of vitals and a box for notes. Sure streamlines what you have to write down. This folds into my pocket, I can add notes to it, then I handover from it in the morning.

I NEED THAT PROGRAM!!!!