Giving report on med/surg floor

RescueNinjaKy · Feb 24, 2016

My report consists of what they came in for/diagnosis. Procedure that we did, like stent or cabg, rhythm, vitals ok? If not I say bp runs low in the blah, asymptomatic, how they get up, wounds/incisions if any, anything special (drip rate if any, weird labs, anything that needs a heads up, like they're confused) and then what we are doing next, like npo at midnight for a stress test.

I find it unnecessary to say where their iv is because you'll find it in your assessment. And their last prn is something I look up beforehand anyways. I like to look up my patients meds right when I get to work so I can plan my day. And I write down what prn it is, the freq and when they last had it.

nrseduk8ter · Feb 24, 2016

"All I feel like I have down right now is diagnosis, IV line location, any wounds/sutures, and when last PRN meds were given. And then I'm kind of at a blank and missing things."

When I was in nursing school, I had a preceptor that used the body systems as a means of providing report. I adopted this system and have found it useful. Most times, the nurse I am reporting off to has no questions or very few. The system is below, if you want to consider...

Neuro - N

Pulmo - P

Cardio - CV

Gastro - GI

Genito - GU

Derm - here I document any skin issues or potential for same, also if on waffle mattress etc.

Act - here I document activity and VTE (SCD/Teds) as well as safety (up w/ assistance)

IV - here I document where, what kind, IVF infusing

I use this to keep me focused in getting/giving report

Other things can be added/deleted as you see fit. Everyone has to find what works for them but hopefully, you will find some use in this or at least a way to tweak it for your benefit.

Best wishes to you as med/surg can be a beast!

Karou · Feb 24, 2016

Do you write down when you recorded report? You need to make yourself a cheat sheet.

Always start with their admitting diagnosis/complaint. Know the date of any surgical procedure along with incision sites and drains (if any)

Then any procedures/tests/treatments that have been done for it. (Ex. IV antibiotics for UTI, IV steroids for COPD exacerbation, lasix for CHF). Pertinent labs (CHF with BUN>1500, HGB that's low, ect). Any truly pertinent medical history (diabetes, CHF, CVA with residual weakness, amputations, ect).

Specialists on the case (GI when came in with a bleed, infectious diseases specialist, cardio, ect).

Alert/oriented or confused. How they ambulate (with 1x assist and walker, or standby, or independent, ect). How they void (urinal, bedside commode, in continent). IV's (especially if a central line) with any continuously running IVF/drips. Report if they are on oxygen or room air. Any lines/drains on general (foley, ostomy). Telemetry or not.

Pain issues. Location, frequency of medication, last dose given (general time).

Skin/wound care.

Any pertinent social stuff- family at bedside, dont give out info to husband, ect... Also anything else random going on that's not related to admitting dx. Cough, dry eyes with eye drops ordered, HTN requiring PRN medication, sleep aid needed, ect..

Ask if any questions at the end. Understanding how to give a thorough report gets better with time.

tsm007 · Feb 25, 2016

Do you write down when you recorded report? You need to make yourself a cheat sheet.
Always start with their admitting diagnosis/complaint. Know the date of any surgical procedure along with incision sites and drains (if any)
Then any procedures/tests/treatments that have been done for it. (Ex. IV antibiotics for UTI, IV steroids for COPD exacerbation, lasix for CHF). Pertinent labs (CHF with BUN>1500, HGB that's low, ect). Any truly pertinent medical history (diabetes, CHF, CVA with residual weakness, amputations, ect).
Specialists on the case (GI when came in with a bleed, infectious diseases specialist, cardio, ect).
Alert/oriented or confused. How they ambulate (with 1x assist and walker, or standby, or independent, ect). How they void (urinal, bedside commode, in continent). IV's (especially if a central line) with any continuously running IVF/drips. Report if they are on oxygen or room air. Any lines/drains on general (foley, ostomy). Telemetry or not.
Pain issues. Location, frequency of medication, last dose given (general time).
Skin/wound care.
Any pertinent social stuff- family at bedside, dont give out info to husband, ect... Also anything else random going on that's not related to admitting dx. Cough, dry eyes with eye drops ordered, HTN requiring PRN medication, sleep aid needed, ect..
Ask if any questions at the end. Understanding how to give a thorough report gets better with time.

That was extremely helpful. I am making a little template. I know I had to do this when I first started at LTC and then once I got with the flow of things I stopped having to use it. I already had someone ask me in report the date of a surgery and had I wrote it down I would have been able to flow out the information better.

ArrowRN, BSN, RN · Feb 25, 2016

Learning to give report takes time. A good brain sheet will help you keep on track and should work no matter what floor you are on. You can go by "body systems report" but sometimes its usually too detailed for a med-surg floor but it works and keeps you on track, however, the other nurse will be starring at you like come on already.

I usually go by:

Name

Age

Gender

Alert/orientedx

date they arrived

code status

allergies

which service provider has the pt

Diagnosis/why they here

past history

what has been done so far/surgeries etc.

Skin issues/incisions/ulcers/drain tubes etc

then list pertinent things that happen for the day- e.g pt had lots of pain issues or they vomited etc.

diet - GI tubes etc

ambulation status - bedrest, walks, needs help etc

bathroom status last Bowel movement, do they void are they incontinent

room air or oxygen?

other basic info: vital signs stable/unstable if so you gave metoprolol or whatever; any bad labs to report

changes to doctor orders made during yr shift - e.g pt needs labs xyz or will be going for procedure x during that persons shift

Lastly, ALWAYS give Plan for this patient at the end: Why the heck are they still here? every nurse wants to know that.

that's basically how I do my report it took me about 4-6 months to get it down so it will take time and it varies depending on what your med-surg specialty is. I do not get into the review of systems unless its relevant to diagnosis. e.g if the pt diagnosis is shortness of breath then i go into breathing pattern oxygen status lung sounds etc.

Generally report should take 2-5 minutes per patient, then you will stop getting hard stares like "come on already"

tsm007 · Feb 27, 2016

"All I feel like I have down right now is diagnosis, IV line location, any wounds/sutures, and when last PRN meds were given. And then I'm kind of at a blank and missing things."
When I was in nursing school, I had a preceptor that used the body systems as a means of providing report. I adopted this system and have found it useful. Most times, the nurse I am reporting off to has no questions or very few. The system is below, if you want to consider...
Neuro - N
Pulmo - P
Cardio - CV
Gastro - GI
Genito - GU
Derm - here I document any skin issues or potential for same, also if on waffle mattress etc.
Act - here I document activity and VTE (SCD/Teds) as well as safety (up w/ assistance)
IV - here I document where, what kind, IVF infusing
I use this to keep me focused in getting/giving report
Other things can be added/deleted as you see fit. Everyone has to find what works for them but hopefully, you will find some use in this or at least a way to tweak it for your benefit.
Best wishes to you as med/surg can be a beast!

I made a new brain sheet. Haven't used one in a while, but think I'm going to need one here at least for a while. Used your template for my system. I've found that I don't have time to write all my assessments down on paper AND chart them too. Double work. So I've started just circling the systems that are abnormal and jotting abnorms down and check marks next to anything WNL so I know I actually checked it.

tsm007 · Feb 27, 2016

I also wanted to add that I realized after a few days that my current preceptor likes to talk. So I don't think it would matter if I gave everything pertinent I think she would still wind up saying a bunch after I give report.

Here.I.Stand, BSN, RN · Feb 29, 2016

I always start with name/preferred nickname, age, gender, day of admission/surgeries, chief complaint/HPI, medical hx, labs, drips, and relevant family dynamics. Then I go system by system, including lines and drains.

John Doe is a 65 y/o male who came to us on 9/25 following a head-on MVC at highway speeds; he was the belted passenger. Unbelted driver DOA. Injuries include Le Fort type I, II, and III fx, bilateral rib fx, a Rt hemo/pneumo, and an open Rt femur fx. HCT was negative. His face was fixed and external fixator applied to femur; he stayed intubated in the ICU overnight and transferred to the floor yesterday.

He has a hx of DMII and PTSD. Being roused suddenly from sleep is a huge trigger for him. He's estranged from wife; he does not want her to visit, and security is aware.

Neuro: intact

HEENT: Lots of facial lacs, swelling. Sutures intact.

Respiratory: chest tube is at -20 cm suction; 150 ml of serosanguinous drainage out for shift. O2 10 L/min on oxymizer. Coughing/deep breathing/IS use is very painful for him, so I have encouraged his prn oxy every four hours. Lung sounds diminished.

CV: generally NSR, but has been ST in 120s when pain not controlled. CMS intact on Rt leg.

GI/GU/renal: He has a Corpak in for tube feeds. Had many loose stools overnoc, so got his bowel meds switched to PRN. Foley is in, with UOP 400-500 q 4 hrs.

Skin: ex fix pinsites oozing a lot of serous drainage. Has refused to be positioned on his sides, coccyx red but blanchable. WOCN has been consulted, and ALAL mattress ordered.

He has running: NS at 100/hr, Dilaudid PCA with basal rate at 0.2 mg/hr, and Isosource TF running at his goal rate of 70 ml/hr.

WBC counts have been trending up and has been running low grade fevers, so we're watching that closely. K+ was 3.1, and replaced per protocol. He's due for a recheck at 0200.

Plan is to have that femur rodded on Monday.

michlynn, BSN, RN · Feb 29, 2016

If you google "handoff reports" or "nursing assessment sheets" you can usually find a good one to go off of. I always include a brief h&p, current vitals/lab work and then I go through every system - neuro, heent, cardio/vascular, respiratory, GI/GU, skin, IV access, current running fluids/medications and then what the plan is for future care.

chacha82, ADN, BSN · Feb 29, 2016

Do you have a "brain sheet" you use? I go through that with the oncoming nurse and anything major from overnight. We don't usually talk history because we can look that up.

dream'n, BSN, RN · Mar 9, 2016

Maybe I'm weird and I know this technically isn't the 'right way' to give a SOAP report, but I give nurse handoff as a story.

For ie: 221 is Mr. Doe, an 82 year old male admitted on 2/10//16 for pneumonia. Mr. Doe presented to the ER c/o SOB and hemoptysis on 2/9/16. A CXR at that time showed left basilar atelectasis and a hemoglobin was 12.0. Lactic Acid level was normal, O2 sats were in the mid 80s on room air, and VSS. Blood culture were obtained and are negative in progress. Mr. Doe was placed on 2L NC and admitted by Dr. Sanders. A consult was placed to Dr. Clinton in Pulmonology. Dr. Clinton saw the patient on the 10th and placed him on Zosyn, ordered a sputum specimen, and chest CT. The sputum specimen was sent to the lab last night and so far is negative in progress. The CT of the chest was completed earlier today and shows an indistinct mass in the left lung. Dr. Clinton was notified and the patient is scheduled for a bronchoscopy tomorrow AM at 8. He is to be kept NPO after midnight. Patient has been stable this shift with 02 sats in the lower to mid 90s on 2L/NC. He remains afebrile with other VSS. Lungs are coorifice in the left base, but clear otherwise. He c/o mild shortness of breath on exertion and is a stand-by assist with a walker. He has PRN Albuterol SVNs ordered through respiratory, but has refused any treatments today. A & O x 4 and has +1 edema in the lower extremities. He has received PRN Robitussin twice this shift. His cough is mildly productive with green sputum, but no further hemoptysis is noted. H & H is ordered every 6 hours and his last hemoglobin was stable at 11.8 at 5pm today. Of note, the patient takes Coumadin at home for A Fib which is being held at this time. Current heart rate is 70 and regular. Last INR was 1.4 this morning. He is receiving Heparin TID for prophylaxis. Mr. Doe lives at home with his wife, Marie, and her number is xxx-xxxx. Mrs. Doe was here much of the day, but has left for home and will return in the morning. Patient was up in the chair for meals and took 3 walks around the unit. Patient history is remarkable for A Fib, GI bleed in 2012, DM II, and prostate cancer in 2005. IV access is in the left forearm and he is saline locked. Diet is Carb Control and his appetite is good. Accuchecks have been 161, 130, and 110 today. He received 1 unit of Lispro at breakfast for the BS of 161 and scheduled Lantus 20 units at dinner. An INR is scheduled for 4am and if results are above 1.0, the Pulmonologist is to be notified. Plan is to continue monitoring, IV antibiotics, and follow up after bronoscopy complete. Let's go meet him and I'll introduce you.

That looks like alot so I timed myself reading the above as I would in report. It took only 2 minutes :)