Giving/Getting Report

papawjohn · Jun 7, 2006

Hey Lorilei!!!

Report wasn't taught in NursingSchool when I was there (and dinosaurs roamed the earth) but it should be. Few things get nurses more ticked off at each other. In some cases the on-coming nurse seems to feel like its their job to point out gaps in your knowledge or failings in your care. Isn't that ridiculous!!! Or the outgoing nurse gives a long emotional story about their day and labors, but very little about the Pt!!! I'm sure we've all heard how the previous nurse had a horrible trip to CatScan, but the results of the CatScan--no info. What kinda deal is that?!

Two assumptions: 1-That the oncoming nurse does NOT know the Pt. 2-That they DO know the Pt. OK?

1. First, pertinant demographic data. Age, Allergies, DNR?, Power Of Attorney?, LivingWill?, Has been living alone? Etc

Second, Pertinant Medical History: Diabetic? Congestive Heart Failure? Renal Insufficiency? (You specifically do NOT need to point out the appendectomy in '92 or BPH if your Pt is catheterized--etc)

Third, Reason for Admission, pertinant facts involving the diagnositic work-up and treatment. (Example: "Came in the 15th with GI complaints. Workup showed hot GallBladder. Cardiac cleared him after his Echo showed 65% Ejection Fraction. He went to OR with Dr XYZ on the 17th and the lap chole failed." You can make up a similar SHORT description for any Pt that includes the significant facts and NO MORE.)

Fourth, I have the luxury of giving report on 2 pts but they are usually pretty sick. So I run down the entire Review of Systems. Like this:

Neuro: Alert or not? Cooperative? Oriented? Symetrical? Any abnormals are chronic? or acute?

Resp: Vent parameters? Lung sounds? Sats? Number on the Incentive?

CardioVasc: Rhythm? Rate? BP range? Temp? Lines? Drips? Fluids? Edema? (Nothing more aggravating that deciding that this Pt can be put off until you assess that one--then an hour later, you find the Dopamine you didn't know was running has run dry and that the Pt's BP is 70/40!!! And that has happened to me.)

More quickly now. GI system (tube feeds? drains? NG Suction?), GU, Skin issues.

Any nursing actions the next Nurse needs to know about? ("AccuCheck at 10 and 4 with SlidingScale". "24 hr urine finishes at Midnite".)

Then, I go over orders and quickly touch on labs and or family-social service-legal issues.

Then--only then--Did you change the dressing (or is it a night-shift job), bathe, get them out of bed, put in the clergy consult that the family asked about, etc.

That actually takes longer for me to write here, thanit does for me to give report this way.

I ALWAYS write it down and pass it on to the next shift--THAT will save you getting phone calls at inconvenient times.

2d--A nurse who has previously taken care of this Pt might not know as much about them as is in this report so I always spread it out in front of them. But all you really 'owe' them is the changes and events since their last shift.

Hope that helps,

Papaw John

Lorilei-RN-in05 · Jun 8, 2006

Thanks, that helps... I need to make a form to write everything down so I can fill in the blanks...at least till this becomes familiar to me!

dorimar, BSN, RN · Jun 16, 2006

I always give admit date, diagnosis,all docs on the case, code status, allergies, surgeries or procedures (dates and findings), medical history, pertinent labs and Xrays & events on my shift, then my head to toe assessment, drips and titration parameters, vitals, lines and dates placed. If pertinent, i get into pshycosocial family issues. If the nurse had the patient yesterday I just go over what is new, unless they want more info. I always ask if they have any other questions. I know my report is very detailed. Usually this is appreciated, but sometimes i can see the nurse not even paying attenttion and bothered by "too much info". Oh well. I feel it is pertinent or I wouldn't be giving it. They need to know the patient went into rapid afib last week and was converted with iv amiodarone but is now on po amiodarone. What if it happens again. I sarted a new job on a unit last month and the nurse giveing me report for the first time was extremely rude and wouldn't give any info. I finally said, can you tell me your head to toe assessment? She said, "You can do your own assessment" as if i'm not going to. crazy. I do hate it when i see nurses giving people crap during report. Some people use report time as a weapon it seems.

tigerrose · Jun 16, 2006

You hit the nail on the head DORIMAR about sometimes they use report as a weapon. I am not sure as to why, my guess is that they either had a hard shift and someone upset them or maybe they are having a bad day. OR, maybe they are just fed up with nursing all together, and if that is the case, they need to get out of the field or go somewhere else where they will be happy. However, in order to do your job when coming on to shift, those people need to put their differences aside for 15 minutes to give an adequate report of the patient. I am the type of person when I am recieving or giving, I give all info about patient, because I am a detail oriented person by nature so there is no guessing or wondering about anything. I expect the same but I know I won't get the same in report. However, I am the type of person that WILL ask that nurse if she didn't mention something important. There has been times that I was given report and thought of something later to ask and have hunted down the nurse HAHA before she left. Now if it is something visual that I can see during an assessment I won't waste my time and hoping that she took good nurses notes. If that nurse tends to be that way all of the time, take it upon yourself to ask her for a better report. If she still doesn't give a decent report, take it up with your Charge or nurse manager. They will ask you right off if you talked this over with the nurse first before coming to them. If you tried and didn't succeed then at least you tried to fix the problem before getting a manager involved. Think about this too, the nurse may not realize she is giving an inadequate report to you, so confronting her in a non threatening way to fix the problem may be the best solution.

calicofrog · Jul 16, 2006

that is an excellent guideline, I am a new nurse to ccu and always feel so overwhelmed in report, but this makes things thorough and easier.

steelydanfan · Jul 17, 2006

Papawjohn did his usual great job in reply. I would only add that often times, info in report gets garbled. It can often be like a game of Post Office. So, after report, take 5 minutes and go through the H&P, and ER report. I cannot begin to discuss the times my reporting nurse tells me something that it completely wrong as to presenting s/sx for admit, or omits something crucial in pt.s history.

Also, if you feel overwhelmed, do not hesitate to ask for a bedside review.

Go in together, have a brief look at the pt., and ask "is this new?".

With some nurses whose reliabilty I question, it can clear up ambiguities.

dragonflyRN · Jul 17, 2006

Personally, I prefer a written report. Almost like a daily log. Kept in a binder..per patient. Add things at you convience. Look back on previous days if you've never cared for the pt. Good for changes in a pt's condition. Currently...I get a short verbal. Up to me to figure it all out. Hard if you don't know the pt.