Are you brief and to the point? Do you have your labs looked up and include any abnormalities worth mentioning? How about labs ordered for the next shift? Do you remind/point out any new orders? Do you say "uhhhh.... and that's all I've got on John Doe, thanks! Do you add on interesting-but-not-necessary info? Do you see report as a necessary evil?
There is an art to giving report, I'm convinced. Some nurses give it chiseled in marble, and other nurses, like me, give it in crayon.
We do written reports on my floor and a brief verbal to the charge RN. Usually if there's anything crazy we'll do verbal to be sure they understand. It has its advantages because we all usually get home on time but other days people leave out really important issues and that irks me. I must say I've developed really neat handwriting so they'll understand, but I know some of the off-going RNs could use some help in that area too - sometimes it's worse that the doc's handwriting!
I tend to give new nurses and floaters a more detailed report. With only 2 patients, reports can and should be detailed.
Thanks, speaking as a float with only 3 years under my belt, that *is* helpful to get more details on a pt I haven't had before, even if they've been there for weeks.
I am a pretty new nurse but I have created my own sheet with all my pertinent info such as O2, IV site, Pertinent medical hx, specimens needed, wound details, etc. I use this to take report. This helps me make sure I GET what I need. Then I use it through the night and add to it. I put pertinent assessment notes on it. When I do my chart check I jot down the AM orders. Then I use this to give report. Because it's orderly and not just a bunch of scribbling I can make sure I hit all pertinent reports. We are also being encouraged to use SBAR which I need to review and make sure I'm covering all of that.
What I HATE is hearing "yea this pt is pretty good, last BP was 126/84, SR-ST, pretty easy pt" and that's about it. You walk in and find IVPB abx hanging attached to nothing, pt has no IV but they didn't bother to tell you that there is no IV access (mandatory for tele floor) that is sooo aggravating.
I'm the type who does better when I just roll up my sleeves and plow in, when I'm receiving report, which I know is important, if the offgoing nurse goes on and on about nonmedical things something in my mind tunes it out. I do better with just the pertinent facts and then taking it from there. I guess I'm limited, but I can't process the important info and then hear about how there's a BOLO on Susie Snowflake's purple houseshoes and that they might be "somewhere" on A wing, when I go down that way...blah blah blah. Just tell me who's glucose levels were out of whack or who has been desatting. Just the pertinent facts, ma'am.
And since I'm not a big talker I strongly utilize the communication sheet, still with only pertinent info. on it.
I do wander at times and tend to ramble a bit when I'm really dragging in the mornings... I hate that
I don't like to read the kardex to them, and don't like it read to me. I can read. But some nurses prefer it that way, so I just go with the flow. Whatever makes it easier for them to get started (or get out of there).
My favorite report of all time was when I was told (in a very calm, nonchalant way) that a patient wasn't feeling well and their last BP over an hour before was 60/30.
!!
The nurse complained to the charge nurse and my manager that I left report and didn't return ...
I don't like to read the kardex to them, and don't like it read to me. I can read.
Ditto that! I hate that! Honestly, it doesn't tell me anything other than the bare-bones. It doesn't convey the "nurse impression". It doesn't tell me your assessment of the situation.
I have my own "cheat sheet" that I follow. Here's what my report usually sounds like:
1. Room number. Patient name, age, gender. Patient status - inpatient, 23 hours obs etc.
2. List all physicians - attending, primary, medical, cardiology etc. At this point, list if there is a covering Doc (example: Dr. X is cardiologist but Dr. Y is covering till Sunday).
3. Admit date and primary diagnosis. Procedures done (if any. E.g. "Small bowel resection with Lysis of Adhesions") and date procedure(s) was performed. DNR status. If patient had surgery today, I mention time patient came back to the floor (for calculation of post-op vital times and post of voiding time etc.)
4. Allergies and co-morbidities/history
5. Diet and activity status.
6. GU - Voiding status (BRP/Foley). Output amount and quality.
7. GI - bowel sounds, flatus and last bowel movement. Abdomen quality - rigid, distended, soft, non-tender etc.
8. Drains - NG, JP, C-VAC etc. Mention output, amount, levels etc.
Wounds/incisions - Location, type, dressing status. Any special care instructions.
9. Blood Glucose monitoring status (ACHS, Q4, Q6 etc). Last known glucose result and insulin status.
10. Abnormal labs if any - interventions followed (e.g. "H count was 6.2. So pt. had 2 units of PRBCs yesterday. Today H count is 8.6"). Vital signs.
11. IV status - IV site, catheter gauge. Mention if pt. is saline locked. If not, describe all IV fluids running in. At this point I also include TPN or Tube feedings if applicable.
12. Pain control (when was last dose of pain medication given, what was given, pt. preference etc.). Mention PCA (settings) if any.
13. Misc - orders to be carried out (e.g. "Pt. will have CBC, BMP in morning"). Anything else of pertinence (e.g. "Pt is sun downer. gets confused and crawls out of bed. Advise a bed alarm"). Discharge orders if applicable.
Some nurses are happy with my report, praising me for being thorough. Some complain that I give 'em too much info and that a lot of what I give in report isn't needed.
We have voice care (taped) report and 1-6 is the basic info you hear for each pt. A float will want to listen to that but most nurses familiar with the pt will skip that part and go straight to the outgoing nurse's report. That will cover the 7-13 aspects. More or less depending on how thorough the nurse is.
I like taped report. No eye-rolling, no chatter. Outgoing nurses aren't allowed to leave until the oncoming has told them they don't have any questions.
I do wander at times and tend to ramble a bit when I'm really dragging in the mornings... I hate that
I don't like to read the kardex to them, and don't like it read to me. I can read. But some nurses prefer it that way, so I just go with the flow. Whatever makes it easier for them to get started (or get out of there).
My favorite report of all time was when I was told (in a very calm, nonchalant way) that a patient wasn't feeling well and their last BP over an hour before was 60/30.
!!
The nurse complained to the charge nurse and my manager that I left report and didn't return ...
What!!!! YOu thought that 60/30 is unusual?? But those are such nice, ROUND numbers...
I was reported to a manager once because the nurse thought I "wandered" too much giving report. Sheesh.
I get and give report the same way: Just the Facts, ma'am (or sir).
I don't WANT to know every gory detail, nor do I entertain the eye-rollers, martyrs, or inquisitors. If the data is clearly on the Kardex, I don't mention it in report. If the off-going nurse tries to tell me non-critical lab values or starts detailing WNL vitals, I quickly cut them off.
Eff 'em. I am too busy taking care of my pts to fool around with alot of essentially useless information - and I don't have the time to waste on a 1-plus hour report period for the same.
Report is an often time-consuming chore of very limited real value.
I hit the facts. I don't necessarily say "lungs clear, bowel sounds present, urine clear, alert and oriented". I hone in on the assesment based on their condition. If they have pneumonia I'll mention their lungs but skip the bowel sounds unless it's relavent.
I also don't go into a lot of details like "his mother came in and she started complaining about this that and the other and the patient wanted juice at 2:15 blah blah blah blah".
I agree, a good report is an art, giving the important assessments that are attuned to the patients condition and cutting out the crap is important.
sambagrrl
7 Posts
We do written reports on my floor and a brief verbal to the charge RN. Usually if there's anything crazy we'll do verbal to be sure they understand. It has its advantages because we all usually get home on time but other days people leave out really important issues and that irks me. I must say I've developed really neat handwriting so they'll understand, but I know some of the off-going RNs could use some help in that area too - sometimes it's worse that the doc's handwriting!