Giving Report...Please help.

Cuddleswithpuddles · Nov 19, 2011

Hi SweetseRN,

No tips on personal preference other than just try to get to know your colleagues and what they prefer. However, know that it is still YOUR report. Be an advocate if something truly concerns you even if it is considered insignificant by some people. You cater to preferences as a courtesy, not as an obligation.

Personally, I like it when I can follow a written report. I like looking at charts and the nurses' "brain sheets" while the other nurse is talking. I am more of a visual person. I don't absorb things well just by hearing about them.

Does your facility have a report sheet with a standardized format like SBAR?

SAHMnurse · Nov 19, 2011

I will be interested in hearing responses to this post.

I haven't worked bedside in 10 years so I'm a bit rusty. I worked ICU and my report went something like this:

Name, age, gender, diagnosis, history...

Then I would discuss each system:

Neuro

Cardiac

Lungs

GI

GU

Skin...

Lab values

Then I would give location of lines and drips the patient is on. Preferred to be at bedside.

Any procedures for the next shift...

Then we would go over 12 hour chart check.

If you are taking a large patient load, your report would probably be way less detailed.

What does your report look like now?

SweetseRN · Nov 19, 2011

We have SBAR and no one uses it unless we get a pt from another floor or when they come back from a major procedure. The way it's set up wouldn't really work for report. I do like what you said here though, "You cater to preferences as a courtesy, not as an obligation." That helps.

SweetseRN · Nov 19, 2011

Right now my report is kinda all over the place. I hit as much important info as I can but its not in any really organized format, it's basically just my assessment and notes from the day. It's really an organization thing that I need to get used to following.

Krista09, BSN · Nov 19, 2011

your report will come with time. when I first started I went through the systems (cardio, resp, GI etc) any psychosocial, then what ever you missed. once you become more experienced your report will come much easier. I found this to be one of the hardest parts of being a new nurse. ask your colleges for pointers and if they have questions, give it time. good luck :)

SDALPN · Nov 19, 2011

I keep my own temporary notes. In my personal and temp notes I write med times, diagnosis, any pending tests and results if available. It helps you to not forget something and then for report it makes it easy. After that the notes get shredded. If I got through my shift fine with the notes I made, the next shift will be fine with the report I give based off of my notes.

beachbumRN88 · Nov 19, 2011

report

name age code status allergies

history

diagonsis

doctors on the case

neuro

-alert & oriented?

-peerla?

-fevers?

-restraints?

-sedation?

-follows commands

cardio

-rythym?

-heart rate trend

-sbp trend

-edema

-pulses

-scds? teds?

resp

-intubated? size of tube, position at the lip ventilator settings

-how do they sound clear course crackles?

-secretions/cough

-is

-abgs and o2 sats

-chest tubes, output or ct, suction or water seal.

gi

-diet

-bowel sounds

-bowel movement

-tube feeding type, rate, goal, residuals

-blood sugars

-drains or ostomies

gu

-foley?

-color of urine

-output #

-important labs creatinine*

-dialysis access (shunt)

iv

-left or right

-access picc, central line? how many lumens

-whats medications are going into what lines and their rates

skin

-any breakdown or abnormals

family

-whos who. hippa code

-any dynamics the rn should know about.

labs

orders

locolorenzo22, BSN, RN · Nov 19, 2011

Report outline(using unit developed SBAR sheet for pass-off, and passing sheet back and forth between shifts for basic information.)

Name

Chief Complaint

Reason for admission

Doctors on case

Code status

Allergies

Isolation Y/N if so then what for?

Medical History

Surgical History

Pending/Resulted tests or procedures

Activity Orders

Diet Orders

SCDs or TEDs on patient

Then, Assessment

Neuro

Pain

Respiratory staus(02 yes or no)

Cardiac system

Edema

Heart rate/rhythm

GI-last BM/foley yes or no/ color, clarity of urine

Skin

Psych

Musclosketital

IVs-locations, fluids, rates

current important lab values

any cultures or UAs done?

New orders for shift

To do orders for oncoming shift

Vital signs throughout day, including blood sugars if ordered

I always write myself a new assessment sheet to staple to the pass along sheet, for two reasons:

1.Next shift cannot say I didn't tell them something or discuss a system issue- it's written right here, we use this for communication as well, and YES, I did- It's written right here.

2. So I don't forget something that occurred during the shift, that needs followed up with during the next shift.

Hope this helps! I would seriously encourage ALL units to use a pass along sheet for basic patient information, it helps prevent the time to write out full histories, tests, admission stories, etc.

nurseprnRN, BSN, RN · Nov 19, 2011

i used to struggle with that as a newbie-- i think we all did-- and it finally occurred to me that when they said "head to toe," that's what they meant, sorta.

so i started with "head"-- neurological status, including behavior and emotional, pain, diagnostics...

moving down, i got to chest: cardiovascular: ekg, vs, perfusion, exercise tolerance for adls, diagnostics, venous, whatever is pertinent, i&o, edema

and lungs: breath sounds, ventilation, gas exchange, dyspnea on exertion, whatever, diagnostics

then belly: appetite, bowels, pain, whatever else in there pertains to the case, like liver, pancreas, ostomy, etc. this is also where i threw in endocrine (dm, di, thyroid, etc. if indicated)

gu/gi is next -- urine, renal labs, reproductive problems, etc.

moving on down, then i did ortho, which if you're not on an ortho floor with particular problems can be mobility, strength, and maybe dme

skin problems or not

psychosocial-- visitors, home issues that will influence care or discharge planning; pt teaching (ongoing and needed)

Esme12, ASN, BSN, RN · Nov 19, 2011

right now my report is kinda all over the place. i hit as much important info as i can but its not in any really organized format, it's basically just my assessment and notes from the day. it's really an organization thing that i need to get used to following.

i always had 2 formats for giving report and then the things i would not leave out whether or not the nurse i was giving report to wanted the information. this will come in time, however i suggest right now you give the report you wnat to give whether or not they like it, so you can learn. experience will give you the rest later.

i have attached 2 documents that you can download and make copies for your self to help you lear what is important and to hepl you keep organized....the rest will come with experience. i take no credit for theses. they were made by a beloved an emeber who passed away a few years ago but her legacy lives on....daytonite...rip.

critical thinking flow sheet for nursing students

.

student clinical report sheet for one patient

i hope this helps....:redbeathe

a2osch · Nov 19, 2011

I agree with several people. And like a few have said, make it your own report. In the ICU, we go by the systems, gtts, lines, labs, vent changes, etc.

Another thing to include is patient specific information. Does this patient have maybe a family "issue" or discussion that is going to take place? Is there going to be a family meeting? Is there information the patient doesn't want the family to know? This is information that isn't maybe medical-related, but patient-related. I don't know about other nurses, but many times you're not only taking care of the patient, but the family as well.

As far as format for my report, I include the following:

Patient's admit date, why they were admitted, if they were direct from the ED, were they a code, or from the OR. If anything new was found, allergies, code status, and who their attending physician is.

Neuro:

pupils, sedation scores, withdrawal, titration in sedation, if the patient reacts better to a certain combination of sedation, follow commands, moves extremities (purposeful or spontaneous)

CV:

heart rate, PVCs, if this is a new heart rate or not, any gtts for BP. What their trends in BP are, if anything triggers drops or spikes, etc. Temperature trends, if they've spiked a temp, what was done, what they've been running. It's also important to note if the patient runs a lower than normal blood pressure. Edema, peripheral pulses, art lines, CVP, SCDs, DVT prophylaxis, coumadin, PT/PTT/INR, heparin gtt and for what reason, etc.

RESP:

intubated? size of ETT, location at lip, vent settings, any changes in vent settings, lung sounds, lasix given?, breathing treatments, sputum characteristics, ABGs. CPAP trials? Did they do well, what the CPAP settings were. Have they been extubated and if so, what time. Also, were they extubated and then needed re-intubated? If not intubated, amt of O2 on, if it's been titrated up or down, do they have a CPAP from home or will they need to go home with one, do they wear Bipap at night. Do they need any sputum cultures, CXR changes.

GI:

nutritional status, if they can only tolerate certain consistencies, did they have a swallow study, do they have a feeding tube (keo here in the burgh) or do they have and NG. Tube feeds, are they at goal, flushes, residuals. If they have an NG, is it to LCS, clamped, consistency, output for the shift. Bowel sounds, abd characteristics, bowel regimen, BM and consistency. C. diff or hemoccult sent? Do they need any cultures? Do they have Accu checks? Are they q6, q4, insulin gtt, etc.

GU:

Foley? urine output and characteristics. Cultures sent? Are they a renal pt? We have an electrolyte protocol that we have to keep an eye on the Cr and if it's above a certain level (for us, 1.5-2.0) we are to consult our physician. Do they have dialysis? Schedule of dialysis days or CRRT, amt removed, dialysis catheter problems.

SKIN:

Any skin problems? Specialty mattress ordered or if they're on one? Do they have a enterostomal consult? Anything else (Prafo boots, waffle boots, etc). We have a big drive for skin prevention in our hospital and I'm sure many others due, as this isn't covered by Medicare if it isn't noted a patient/client and a skin problem upon admission.

IV:

IV access, any difficulty with IV placement, did we have to call? Do they have a PICC? Was it at bedside for in interventional radiology, date IV's were placed.

We also discuss any electrolyte replacements, rechecks, troponins, any 12-lead EKG done, if IVF were added or changed, any gtt changes or if they were able to be titrated off. And like I said, anything patient specific.

I hope this helps! You'll get the hang of it. If you don't have a format, you can always free hand make one that you can follow. That way you will be able to follow it. Also, practice writing it down. When I look up my meds, I flip my nurse hand off report over and list my shift by hours. That way if I know something is due at this hour and if anything happens, urine output, gtt/BP/sats changes, I can list it under that time slot. I write a column for NOTES and if things need changed, i.e. insulin changes. Do what works best for you, something that will be easy for you to follow and eventually, won't have to think twice about. If you chart well, then if there is something that you may have forgotten, the following nurse will easily be able to figure out if it was a new change or if it was something that has been occurring and if the MD is aware of it. I hope this helps!