Giving report to the next RN?

VANurse2010 · Oct 13, 2016

Basics: Name, Age/Sex, Code status, Allergies, Attending physician/MD team/relevant consults

Relevant Past medical history

Followed by: admitted on (date) from (home/SNF/etc) presented to (ED, clinic, outside hospital transfer) with (chief complaint). Chest Xray done showing RLL PNA started on azithromycin. Relevant events during admission... Plan for any procedures/tests. disposition/ D/C plan.

Systems:

neuro, resp., CV, IV access, GI (e.g. npo since midnight), GU, Musculoskeletal/Derm, Psychosocial issues. Relevant labs (say what was low or high and what you replaced or did about it).

Do it the same way every time and you'll become more organized.

AJJKRN · Oct 13, 2016

Pick a report sheet aka "brain" and stick with it, read it off the same way every time giving report to become more consistent. The content that you give is specific to your facility's expectations I would think.

Im a floater and made my report sheet specific to me...

Across the top: room number, patient name, age, DOB, MD, code status, admit date, allergies, etc

Then essentially it reads:

H&P, PMH, wounds/dressings, dialysis accesses, tubes(JP, t-tube, wound vac, chest tube, etc) IVF, IV sites, pain pumps, diet, blood sugars, feeding tubes, VS, O2, Bipap/CPAP, trach, neuros, ETOH WD, activity, voiding, labs, POC for DC

This all fits on a half sheet :sarcastic:

Hope it's helpful!

Lev, MSN, RN, NP · Oct 13, 2016

Name

Age

Gender (if not obvious from 1st name)

Code Status

Allergies

Diet

Isolation

Relevant medical and surgical history

Orientation level

Reason for coming to hospital

Hospital course

Psych/social issues + family contact info if dementia patient

Assistance level/now voids urine

Any issues this shift

Relevant abnormal assessment/lab findings findings.

IV - location, gauge, and what is infusing through it including antibiotics, ivf, and electrolytes

What needs to be done

Plan of care

NewMurse1014 · Oct 13, 2016

Maybe I'm not organized, but I don't usually go into every details about the pt. From what I observe, almost all nurses print out either the pt's list or pt's labels (which contains all basic info like room number, name, age, sex, code status, allergy, attending MD), so I don't need to repeat all that info. I usually try to keep them short, going from "big" to "small":

1) room number + name + diagnosis + pertinent hx (14-1 Mr. Jones came in here with CHF, hx of MI in 2015)

2) what we're doing for them, what's the plan to get them out ASAP (basically we're diuresing him with 40mg IV lasix q8h with good output, plan to go to echocardiogram in AM)

3) any important/pertinent/abnormal findings (BNP is elevated at 1234, troponin 0.08 rechecking every 6 hrs, he's still on 4L O2 NC satting 92% and gets dyspnea on exertion, crackles on the bases)

4) any other small details or almost normal findings (otherwise he's A&Ox4, NSR on the monitor, get up with a walker with 1 person assist, GI/GU ok, skin intact, IV in the right AC 20g saline locked)

Usually it takes less than 5 min per pt, including introducing the oncoming nurse to the pt and saying goodbye to the pt. You'll find your way of giving report.

CelticGoddess, BSN, RN · Oct 13, 2016

I give basic information when I do report:

Pt Name, age, orientation, code status, diet, MD name

Reason for admission, pertinent history, IV's, on O2 or not, tubes/drains/ etc. if they get resp tx, wounds, wound care Pain meds/what/when/time.

PT/OT/ST if applicable, posible dc date, or why we are waiting (we get a lot of placement patients)

And if anything happened overnight.

Typically I am finished with report in 20 minutes or so, unless I have to give to more than 1 nurse and one of those nurses is the nurse who asks who did the appendectomy in 1978. I also ask what questions the nurse has from me. So far, everyone has been okay with my report.

Cat365 · Oct 13, 2016

Previous posters covered it. It will be individual to your unit. Make up a form or ask another nurse that you like getting a report from for theirs.

I would add on my floor any upcoming tests or samples I hadn't collected.

Basically keep it short, organize it the same way every time, and include what you would want to know if you were assuming care.

GE90 · Oct 14, 2016

background

major stuff that happened today eg, ot? ct? xr? and so on.

obs this shift+previous shift, stable? abnormal? doctor notified? interventions? results?

input? output? mobilize? pain? social? behavior?

future plans? when will happen?

what needs to be done? dressing change? bloods? meds? so on and on.

u've got any questions?

I thing I fking fking fking hate is when people interrupt me during handover, sadly there is a nurse in my unit who's always like this, every fking time I handover to her I bet you my genital I'll forget to mention something

NurseGirl525, ASN, RN · Oct 14, 2016

Name, age, code status

allergies, history

why patient is here to begin with

what all surgeries and tests being done and what they showed

neuro, resp, gi, gu

access and skin issues

any abnormal labs and if accuchecks need done

anything I did not get done on my shift and needs to be addressed

NurseGirl525, ASN, RN · Oct 14, 2016

I will say mine is a bit more detailed as my patients may have had multiple surgeries and procedures done.

HouTx, BSN, MSN, EdD · Oct 14, 2016

My organization (and many others) utilizes a standard format for Bedside Shift Report. New hires are trained as part of orientation. Although BSR sometimes gets a bad rap, new grads have told me that they enjoy it because it decreases "bullying" and intimidation by experienced nurses. ... they can't do it in front of the patient.

It's a waste of time to read everything in the chart to the oncoming nurse. You do need to inform them of any new developments and what has been scheduled or will occur on their shift. Don't worry - you'll be fine.