Giving/getting report

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.

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."

​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.

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

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.

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

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.