Giving an awesome verbal report?

[Maddy_Rose]

Hi there, I'm a new grad that will be starting on a orthopedic/vascular surgery floor very soon. I feel...OK about my ability to communicate the most important information about a patient to another nurse, but I want to get better at giving a more thorough and logical report (I mean not jump around in my thoughts as much).

We use kind of a combination of verbal and written report on the floor - if nothing notable happened with a patient we might just write a little blurb about them for the nurse coming on to read. But if a patient is new or had a lot of stuff go on a verbal report is usually done. Do you guys have any tips or strategies for organizing your thoughts, or the best way to give a thorough picture of a patient? What's the most effective order of information you find works?

Any input is much appreciated! :)

[NCRNMDM, ASN, RN]

Every nurse has his/her own way of giving report, and you will develop your own way over time. Personally, for me, I want the important details, vitals, lab values, etc. I don't want a five day history of the patient if those details don't pertain to my shift tonight. I generally move in a head-to-toe fashion (or try to at least). My report goes like this:

Brief introduction (patient's name, DOB, Dx, allergies, etc)

Mental status and orientation (I also mention any psych history here if it pertains to the care that will be given)

Oxygenation, breath sounds, sats, etc.

Heart sounds, heart rate and rhythm, telemetry, capillary refill, etc (anything to do with circulation and perfusion).

Bowel sounds (NG tube is also included here if present).

IV access (and anything that is currently infusing).

Urinary continence and system (Foley, urinary output for the shift, etc).

Bowel continence (number of stools, etc).

Integumentary system (skin condition, any wounds, any surgical incisions, edema, bruising, etc)

Surgical drains (if present, how much they've drained, consistency, etc)

Pain management (last dose of pain meds, location of pain, characteristics, etc).

Scheduled meds (and when they are due next).

Abnormal lab results, and labs that need to be drawn during the shift.

Any tests that the patient might be going down for during the shift.

Final details if there are any.