Giving/getting report

jennilynn · Jul 26, 2012

I give admitting dx, brief hx, go over the not mets (if you chart by exception), how they ambulate, fall risk, fluids, IV access, o2, and vitals. Then, if time permits, any extras.

evilolive, BSN, RN · Jul 27, 2012

Diagnosis, pertinent history, ambulation, treatment plan, and discharge plan are my necessities. It's a bonus if you tell me what fluids they're on, and how they take meds (I take a lot of medical overflow, and it would be nice to know if I need to bring an applesauce into the isolation room with me).

Sometimes the family issues during report are overkill. I don't need the whole story, just a "heads up."

Ruby Vee, BSN · Jul 27, 2012

this is in the general nursing discussion, so i don't know if you work on a floor, the icu, an outpatient setting or ltc. if it's the floor, a lot less information is required than the icu. in the icu, we want diagnosis, history, date of surgeries or other invasive procedures, review of systems, lab values, treatment plan and provider. sbar is a good format to use.

loriangel14, RN · Jul 27, 2012

It also depends what kind of floor you are on. I am on a Complex Continuing Care floor.Lots of rehab,palliative and seniors waiting for nursing home placement.Some medical acute care patients. Many of our patients are with us for several weeks, if not months.We don't introduce them and give a history in report, just anything out of the ordinary, e.g.pain issues from that shift etc. Anything like ambulation, transfers etc/ can be found on their white board.

WildOne · Jul 27, 2012

Hello all,
I am new to allnurses.com and also new to nursing. I'm curious to know what items you feel are critical to know/tell in report and what items would you rather be left out and found on your own. After introducing the patient, what they came in for, and a brief history, is there a specific order you go in when giving report? Do you do a review of systems when giving report or just mention pertinent assessments?
I just want to make sure I don't give a horribly disorganized and uninformative report and that I know what items are critical to be aware of when receiving report...
Thanks for any replies!

In the hospital I work for each floor has an admission question sheet that the nurse from the floor asks the emerg nurse for example on cardiac floors the questions are more tailored to heart health while on end of life floors it has more to do with pain control and family

EnlightenMeRN · Jul 27, 2012

Thanks for all the replies! Very helpful!

Right now I'm in a residency program at a large hospital, so I am kind of getting a taste of different floors by working a few days on each. I'm not really sure which floor I'll end up on, although I figure it will be some type of med-surg floor.

allnurses Guide · Jul 27, 2012

On our floor (ICU stepdown) we generally give:

Neuro, cardiac (on tele? What rhythm?), respiratory (on O2? Trach? etc), GI/GU (Foley? Bedpan? Up with assist? Diaper? Flexiseal? Last BM? Urine output?), skin condition (wounds? incisions? drains? Wound vac?), IV locations, types and what is running in them at what rate, pain status with what meds are available and last given, T-max for the shift, extremities (CVA history? Ambulatory? SCDs in place?), core measures such as vaccination status, SCIP protocol, AMI protocol, pneumonia protocol, CHF protocol etc as applicable, diet, psych issues and family coping. We are in the a habit of giving very thorough report. It goes pretty quickly because people are pretty good about not interrupting and working together.

emtb2rn, BSN, RN, EMT-B · Jul 27, 2012

ER can very well be: suspected/known dx, location of iv, meds rec'd & pending test or results.

Good Morning, Gil · Jul 27, 2012

What RubyVee said, but if I were on the floor, I would want the same information. I think it's good for every nurse to be informed lol.