Giving Report

jmgrn65, RN · Jul 10, 2006

Sometimes thinking of the patient from head to toe (so to speak) helps

pat is a&o vss, lungs clear bs + etc, or another way we have been doing because of JCAHO (so they say) is SBAR S=situation B= Background A= assessment R= recommendtions. Hope this helps

FreshRN05 · Jul 10, 2006

when giving report ( we do ours via voicecare...not nurse-nurse) you do not have to give head-to-toe report on your patient. Focus on what the patient is in the hospital for and if there's any changes in his/her condition...This is how I do mine:

1) Patient's name, age, gender and Attending Doctor and any Consulting MD's

2) Diagnosis, medical history, allergies

3) mentation (a/o; nonverbal.......)

4) IVF, IVPB, any abnormal labs and vital signs

5) Pain status and pain control med

6) any treatments (dressings, NG tube, TPN's.......)

7) any pending or planned procedures (AM/PM labs, X-ray, CT's......)

8) diet and activities (regular, NPO, diabetic/renal duet; ambulatory with or with no assist (one on one or any assistive device)

Just make it short and simple...Trust me, the nurse listening to your report only wants to know the important stuff...they don't wanna hear a long story....

I carry my report/assignment sheet with me to help me with my report at the end of the day.

Hope this helps.....GOODLUCK

purplemania, BSN, RN · Jul 11, 2006

This has become a critical nationwide issue and a Patient Safety Goal for JCAHO. Your Quality Assurance or Risk Management person in your facility really ought to come up with a plan that is good for the whole facility. But at the very least, follow FreshRN05's advice. Do not get bogged down with psychosocial stuff like "he said/she said". Ask the oncoming staff to critique your report then don't try to justify yourself when they give you responses. You don't have to agree with them, but they really might be telling the truth and at any rate will probably learn something about yourself. Congrats for being concerned. This is a real safety issue.

nursentj2005 · Jul 11, 2006

Try to make a standardized report. That's what I did at first. Has everything you would want to know and you just fill it in during the day. Or you could follow the kardex. Does your hospital have kardexes?

nursentj2005 · Jul 11, 2006

Try to make a standardized report. That's what I did at first. Has everything you would want to know and you just fill it in during the day. Or you could follow the kardex. Does your hospital have kardexes?

manna, BSN, RN · Jul 11, 2006

Mine is similar to FreshRN... I'm still getting the hang of giving report, and by the end of some 12 hour days my brain isn't functioning well enough to be very organized about it... thankfully I have some great coworkers! :)

Patient name, age, gender, doctor, admitting dx and circumstances, history

Example, "In bed 2, Mr. John Doe. He is a 99 year old patient of Dr. XYZ. He came in through our ER yesterday for chest pain x 3 days, etc etc etc. He has a history of htn and IDDM"

As far as head-to-toe goes, I usually only mention things that are NOT WNL or have changed during my shift.

I'll go on to mention orders, abnormal labs, VS, IV site and IVF, procedures, diet, activities... like I said, FreshRN's list was much more organized than mine.

You'll get the hang of it with practice!

CardioTrans, BSN, RN · Jul 12, 2006

I work in CCU, so mine may be a little different. But here goes.

If the nurse has never taken care of the pt or its been awhile:

Name, adm date and diagnosis, pt of Dr ___, allergies, history, plan for next 24 hrs.

Neuro:

CV: SR, rate, BP, temp max,

Resp: Vent settings, ETT size and location or O2, O2 sats

GI: include tube feeds, NG tube etc

GU: include foley, and output for last 12 hrs

Integ:

Access: where and what size each IV is..... IV drips etc.

If the same nurse that I got report from in the am is back that night........

No changes or tell them only the changes. I always review the vent setting, ETT size and location.

Any tests that were done throughout the shift, or any major issues through the shift.

Hope that helps.

grinnurse, RN · Jul 15, 2006

The hospital that I work at, per JACHO, has a sheet that is to be filled out, Kind of like a "portable" kardex that is supposed to pass from shift to shift with any changes but unfotunately, it is not used as intended.

What helps me out the most, is to take my initial report in black ink, and then throughout the day, I add to it in a different color of ink-usually orange of any changes, new procedures, labs, tests, changes, etc. We always get a sheet with the patient's name, age, dx, doc, diet, etc and then add the other stuff such as meds, IVPBs, IVs etc. In report, just try to give the facts. It takes time to get the hang of it, but as they say, "practice makes perfect"!

DarlinNurseRed · Jul 23, 2006

I have had the next shift of nurses critique me constantly through report...some cannot help themselves, its become a habit.

I worked at a facility that did the taped report instead of face to face,,,i kinda liked it.

It wasn't as time consuming, and you didn't have to wait as long to get started.

Of course, you didn't get to critique anyone,,,how much fun can that be?

pamc217 · Aug 11, 2006

when giving report ( we do ours via voicecare...not nurse-nurse) you do not have to give head-to-toe report on your patient. Focus on what the patient is in the hospital for and if there's any changes in his/her condition...This is how I do mine:
1) Patient's name, age, gender and Attending Doctor and any Consulting MD's
2) Diagnosis, medical history, allergies
3) mentation (a/o; nonverbal.......)
4) IVF, IVPB, any abnormal labs and vital signs
5) Pain status and pain control med
6) any treatments (dressings, NG tube, TPN's.......)
7) any pending or planned procedures (AM/PM labs, X-ray, CT's......)
8) diet and activities (regular, NPO, diabetic/renal duet; ambulatory with or with no assist (one on one or any assistive device)
Just make it short and simple...Trust me, the nurse listening to your report only wants to know the important stuff...they don't wanna hear a long story....
I carry my report/assignment sheet with me to help me with my report at the end of the day.
Hope this helps.....GOODLUCK

Thank you for making that checklist, Im a new grad and hope to start working soon. I am going to keep that with me, if you dont mind. Thanks again!!!:cheers:

lovemusic31 · Feb 29, 2008

thank you so much, everyone, for writing what should be given in report. i am still struggling with that...i have been an rn for 1 year and just started a new job on a cardiac tele floor after being in an ltac hospital. very different. some of the nurses what all kinds of details and then others want the bare minimum. i'm still trying to get the hang of making sure all the info is there for them. it's hard for me to stop what i'm doing through the night to write things down on my paper, but like the other person posted, 12 hours later in report my brain is fried and i don't remember anything. on my first night off of orientation they gave me three admissions!! very overwhelming. i'll just keep working at it till i'm comfortable. it just takes time.