Giving Report?

I work in an ICU and we give verbal reports, but I always write out the following (before I get report) and fill in the blanks with what the other nurse is giving me... That way when they're done and ask if I have questions, I can glance over my list, and see if there's any blanks... I'll try to show you what I do:

History

Admission reason

Contact person (in case of emergency)

IV (I'll include what kind of line/meds infusing)

Neuro/MS

Cardiac

Resp

GI/GU assessment

Skin

Accu checks/serial lab draws...

Meds (including any PRNs maybe given overnight)

Labs (usually only the abnormal ones... unless we are keeping trends of h&h or something)

Things to do (maybe nightshift only gave one of the two units of blood... or I need to ask the MD when they come in about transfer orders...)

All of this REALLY keeps me organized- that way if someone has a question about my patient, and I have a lot going on, I know I can count on my report sheet to help me out.

Good luck!

:smackingfooooo thats a scary one especially if you are doing the report/handover for the first time. I remember when I had to do it on my second clinical placement I was shaking from head to toeeeeeeeeeeeeeeee

i am in ltc, and have been in the same facility for over 6 years. we run "the gamit" in things, so.... when i give report on someone who has fallen/"changed"/etc., i start "head to toe", and only focus on the abnormal data, ie: if pt struck head or not, slid out of chair....if pt a diabetic, the accucheck if possible/necessary.

hope this helps.

suebird

I start with the pt's name, age, Dr., DX, admit date, drug allergies, and code status. I would then give brief significant PMH. Then I would report the pt's chief complaint as to what brought them to the hospital. I would then use a system's wise approach~ neuro - Pt pleasant, alert, & oriented ~ anything else you might want to add. And then just go down all systems. When I am done reporting off on my assessments then I will mention IVFs, treatments, labs, medications, report if the pt was working with PT or Resp. I would also report on any tentative dc planning.

That Was A Great Way To Give Report!!!!!!!!!!!!

I have made a "Brain" that has worked wonders for me. I leave space for the patients sticker with bar code, so that I have it handy.

I have the pt's dx, hx, cc, doctor, admit date, accu check frequency, vitals, i&o, diet, medications with times due, and a misc.

I also like to use different colors of ink for my morning report, and a different color to use when I do my assessment to note any changes. Just my way of doing it tho.

I made up my own form: 1st column- room #, admit date, allergies, dr., time of assessment; 2nd column- pt name/age/gender, code, diet; 3rd column- dx(diagnosis),hx (history), tests, & room for notes (foley, BRP, BSC); 3rd column- med times & types; 4th column- IV sites/gauge, fluids rates/type, BS score & units given.

Look at chart for new orders before pulling any meds, check labs/tests/physical history by admitting Dr & include some info in notes section.

That way I'm not caught out by the nurses who act like they're "SUPERNURSE", & want me to give them everything, & I do mean everything on patient.

Sometimes, I say, "Of course, if you're interested you can read that information for yourself in such & such section of the pt's report."

I make copies of my blank form & am ready to go!

Everyone, as you can see, has a different way of giving and taking report. You too will develope your own style soon. But as for that written report, just start from admitting diagnosis and the course of events during the hospital stay and the outcomes of the procedures/tests and further plans (what is the problem and what are we doing about it). Go through the head to toe assessment. This should cover any exceptions to the norm. Its should be understood by the nurse taking report that if you dont say lungs clear A&P bilat to the bases, and this patient is not a respiratory/pulmonary case, then it should be understood as lungs clear. How thorough you want the written report to be is up to you. As long as the pertinent info is included. If the oncomming nurse wants to find out more, it can always be researched in the chart or pts old records. There was a previous post about some people wanting to know everything; however, if you are giving and receiving report on six to twelve patients (depending on the floor and RN LPN ratio) there is no time for what color underwear the patient was wearing upon admit. Hope this helped, good luck.

"It seems that I always leave something out or put it in the wrong order."

It sounds like the facility youre in has their own ideas as to what to include and the correct order: ask your preceptor or DON!

this is an old thread but here goes

in my last placement and really concentraing on doing hadover(giving report) and never knew what excalty to say with any confidence.

so i went home and made up a list of what i thought i'd like to know

bed number

name

age

consulant

reason for admission

past medical history

vitals any altered labs

neuro

pain control/medications medication for disharge ready

discahrge planing sw, ot, pt transport

diet diabetic blood glucose soft/puress ivfluids

elimation catether bowels etc

hygiene

wounds/temp/ iv abx

pressure area care/mobility

i'm in the UK we don't do nursing assesments like the USA and i'd only say what is altered from normal

told this to the unit manager as something i've learned and though she has never listened to a handover i've given she liked the structure

I work in a Critical Care Unit (Pulmonary/Vascular/Genral) and we are looking at the way we give report as a whole. We arrive at 0645 in the a.m. and have a brief general report about all of the 14 patients we are caring for that day. Then, we choose our assignment and get a detailed report from the nurse we are relieving. Some of our team suggest that the 15 minute general report is a waste of time, while others think it gives a brief insight into the general running of the unit for the day and the concerns that may arise.

Any input into how other units give and receive report? :nuke: