Giving Report...help please!

All I can say is, you'll improve!

My oral presentation skills have never been my strong suit. We do taped reports, or face to face if we can't get to the taperecorder in time. I do better at face to face, since it's more like having a conversation.

My philosophy is,why say something that they can find out by looking at the Kardex, such as the type of IV fluid. I don't comment on non-problem oriented stuff. I sometimes remember to give labs, esp when they are very pertinant.

I don't mention VS that are not earthshakingly pertinant to the diagnosis. I don't do a head to toe on my reports. I try to give a run down of things that happened, include important pt hx and background info, family dynamics, etc.

I try and write down stuff on my sheet to somewhat help me be prepared. If the pt had lasix, then I and O is important. If they had pain, then a run down on their pain meds is important. Nausea, response to food is important in a surgical pt. BMs are sometimes important to mention.

I only mention the IV site if there is an issue about it. But, a lot of nurses always mention it. Everyone is different, just do your best.

PRNs given during the day and why they were given

Safety issues w/ the elderly/confused

Abn findings on the physical assessment

Abn labs

Pertinent hx

New orders and ?why they were ordered

Pertinent conversations/happenings w/ ancillary staff

Odd time meds or meds that are due as soon as I hit the floor

Results of tests that were done that day

Pain management

Last turn/wipe and dipe....

these are the points that I am looking for in report.

Although some believe it is a waste of time, I also like the general demographics on the pt so I can write it on my paper and not take the time at the beginning of my shift to look the info on the kardex.

It would help to know what type of unit you are on. Different units have different types of report. On my unit (SICU) we do:

Demographics

Very detailed HPI

Medical Hx, allergies

Systems overview (each body system has it's own sub-categories)

When I worked ER for my senior preceptorship the report was more specific to the system that was being treated.

I am an R.N. and, also, a Certified Legal Assistant. Giving a report is similar to introducing evidence in a legal dispute. All evidence should be admitted which is relevant and material and not otherwise objectionable.

Something is relevant when it tends to prove or disprove something of importance. Some types of information that might be "objectionable" to include in a report (as in legal evidence) :rotfl: would be something that takes up too much time, is not objective evidence, is based upon "hearsay", is not the best evidence, and/or something which violates rules of professional or personal privilege (making personal comments about a patient for example). :rotfl:

Another very important thing to give is orientation, proper use of the call light, transfering ability, self feeding ability, mobility aides, etc. It prepares the next shift for how they can help the pt with mobilty, toileting, and other ADLs.

It's good to know how the pt is progressing with PT, OT etc. Any results from diagnostics done is important.

Another very important thing to give is orientation, proper use of the call light, transfering ability, self feeding ability, mobility aides, etc. It prepares the next shift for how they can help the pt with mobilty, toileting, and other ADLs.

It's good to know how the pt is progressing with PT, OT etc. Any results from diagnostics done is important.

All of the above are very important to me. We still have taped report and often I get "no change" , I have to remind a select few that we may have never had this pt. or may not have been here the day before. I also want to know if anything pertinent happened on the shift prior to the ones reporting. The other day came in to find a pt. I had had the day before with a laceration on his head and multiple bruises, with no mention how they had occured. His roomate told me he had falled on the pm shift. Actually got a better report from the roomie than my coworker.

Report is something you get better at with experience, but it also is often unit specific. ICU reports are way different from med/surg reports. I worked most recently on a tele/stepdown unit and would kind of run it like this:

"So and so is 57 y/o man who came to us on Friday with suspected pulmonary embolus. His hx includes HTN, multiple back surgeries, and gout. Apparently they were having trouble with his sats last night, he was in the low 80s for a while. But today he is doing well with sats 93-94 on 2L. I think we might try to wean him off pretty soon." The previous part just tells the story of the patient, what is critical. Depending on the unit, whether the nurse you are reporting the pt to dictates how indepth you get.