Giving Report...Please help.

[SweetseRN]

Anyone have some quick tips on giving a really good report? I am getting better but I still struggle a lot with this. Some nurses want every detail and some just want the basics. I would appreciate SO much if someone could give me some examples or some kind of format to follow.

[DavidFR, BSN, MSN, RN]

Give the kind of report you yourself would want to receive and be happy with. People can always ask questions if you miss something they wanted to hear. And never be ashamed to say "I don't know" Nobody is supernurse and some nurses just love asking picky questions out of insecurity. Nothing worse than a point scoring, "I'm the greatest'" handover. Such nurses should be shot.

[Double-Helix, BSN, RN]

My report goes something like this:

Name

Age

Weight

Allergies

PMH

Admission date

Current diagnosis

History of current illness

Significant events in the past 24-48 hours

Current assessment by system

-cardio vascular

-respiratory

-GI/GU

-neuro

-IV access

Labs due/plans or procedures for the night

Family present/ social concerns

Review meds and orders.

That's my unit standard. But I work in PICU and we like very detailed report. My advice would be to listen to the people you are getting report from. Not just listen to their report in mornings, listen to how they give it. How do they organize their report? Is in understandable? What do you like and dislike about how they gave report? Then experiment with different ways of organizing your Report until you find a system that is clear, thorough and concise and feels right to you.

You'll also find that with more experience, repot gets easier. I used to be a hard time organizing report because I wasn't sure what I should be looking for during the day and what information to include in assessments. Now that I am more used to working, I find I'm able to pull together my thoughts and notes from the day into a detailed report.

But remember that you can give the worlds greater report and there are people who will want it done differently. Can't please everyone. Good luck to you.

[BeenThereDoneThat74, MSN, RN]

As a new nurse, I struggled with this big time. I felt bullied; like the next nurse was just being lazy and didn't want to bother doing their own assessments. Looking back, I see that I was just insecure (yet, I still maintain that some of them WERE busting my chops in report). I do (still) feel that we spend way too much time trying to please others, who, in turn, may give us a crappy report. It has to go both ways. It shouldn't be a contest, but a efficient hand-off (to make sure all pertinent information is reported)

There seems to be a number of critical care nurses replying to this thread (this is not an ICU forium, right?). I think that the lengthy report templates described here are great... for ICU patients. If the OP is a med surg nurse, I honestly don't see going into such detail about each patient (assuming you have 6, 8, maybe 10 patients, this would take an incredibly long time). As a nurse who worked in bone marrow transplant, our reports were pretty detailed, but I've never been a believer in an entire full body assessment in report. I've always felt that 'report by exception' is sufficient. Do I need to specify that the patient follows commands if it is a 30 yr old who had a lap appy? Unless I say "he had a change in mental status overnight" (and went into details about what was done), I think it's understood that he follows commands. I'm not saying you do not include pertinent information (yes, I want to know that lungs are clear, that he has +BS and is voiding, b/c he is post op), but I don't believe I need to reiterate my entire assessment to the next nurse. If VS are stable, I am not going to regurgitate them back to you. You can read that yourself after I leave. If they had a temp issue over the last few days, then I'd mention what the trend was for me.

As far as other important data:

-Tubes, drains, catheters, dressings, IV (fluid type and rate).

-Labs (pertinent: abnormal values, if any drug levels were drawn), and what is being done about them. Also, if any are ordered on the next shift.

-PRN meds given on your time

-*Psychosocial issues* this one is big for me, as a peds nurse. WHo is at the bedside, and how that is going to effect your shift. Does the child willingly take his meds, and any tips/pointers on how to make your shift easier.

[sweet~revenge]

You're getting lots of great advice. I also struggled with report when I was a new grad. I hated giving report with a passion! It didn't help when some of the nurses gave me a hard time and asked all kinds of questions that I didn't know the answer to. I felt so bad when I didn't know every detail of the patient's medical history but when you have 6-8 patients on a med surg floor, you just don't have the time. If you don't know the answer, just say I don't know and let the oncoming nurse look it up when they have time. If they had the same kind of day you had, that will probably be never .

I always start with name, room #, date of admission, and admission reason and go from there. I start by addressing the admission reason, if it's resolved or if there's a new problem, related test results, symptoms, etc. I don't cover every test done since admission, just those that are recent and/or positive. Then I usually go from head to toe, they're A&O x 3, ambulatory, voiding, IV site and fluids, o2, skin, contact, blood sugars, etc. I also let them know about the patient's general attitude, for example are they irritable, pleasant, do they refuse meds and treatments, etc. Is the family crazy, really nice, involved, demanding, willing to be called in the middle of the night to help calm a confused pt? Finally I try to give the plan of care for this pt: scheduled tests and labs, consults, placement, and discharge plans.

Just try to give as complete of a picture as you can, but don't worry about including a bunch of old info that isn't really relevant. You'll get there, it just takes time and practice.