I am still a fairly new grad. I graduated in December. Worked in California for about 4 months after taking boards, and then moved to Arkansas, and work here at a hospital for about a month now.
Does anybody have advice on how to give report to the incoming nurse? I just always seem to feel like I miss stuff. i do so much during the day and just don't write it all down, then I am sitting there and it all doesn't come to me.
I am a new nurse and I am aware that this question is a little old but I wanted any new nurses to be able to use this if wanted. I work on a Med-Surg floor and each morning I give report to a new group of nurses. One wants just the "need to know" and the other stuff (hx,normal labs..) that can be looked up on the chart does not need to be told.Then the other set ask alot of questions and want info. from 3 days ago.So I made this tool to help me try to remember everything.:heartbeat
Giving Report to on-coming shift:
In room _____ we have Mr./Mrs.______________________, a ____ y/o, male/female of Dr.______________ / Consultant's __________________________________________.
Admitted with __________________________________ and Hx of ______________
Code status is: _________. If DNR, is paperwork in chart? Y or N Allergic to ________________________________________.
A&O x___ (name, date, place) Daily wt of _________. IV of _______ at _____ml/hr at the ______________________. Activity level is ____________________________. Dressing changes: ______________. Incision or wounds (loc. & desc.): _____________________________________________________________________.
On 02 at ________. Type: _______. 02 stats: _________% Any breathing tx: ________
_____________________________. Why and what med? _____________________________________________________. Tubes: Foley, ostomy, NGT, suprapubic,JP.
Desc. & amt. of drainage:__________________________________________________.
Last BM:___________ Continent or incontinent of bowel and bladder? Voided how
much? ______________. Diet: _____________. Ate how much of diet? _____________.
Fingersticks are __________ with a sliding scale of _______. Last FS at _____________
was _______ and was covered with _____________. V/S are stable/unstable.
Any abnormal assessment findings? __________________________________________
Pain: pain level of ______ at _______where __________, treated with ______________, response to treatment is ____________________________________________________.
New orders include: ______________________________________________________.
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.
This is pretty much how I give report. Dx, hx, allergies, followed by a ROS, upcoming labs, BBGs, complications/problems/improvements, and overall picture of the patient including any family issues.
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.
writing things down as i do along throughout the shift is the only way i can do it. it took me a while to figure out a system, but i finally have one that works. i keep a binder with me that includes a "cover sheet" which i create for each pt. on the right side is full systems assessment, iv site, orders, and some other main items that pop up on my floor. on the left is blank space for me to circle med times, write abnormal labs, and jot down notes throughout the day - the most important part! if i don't write those notes down (i.e., spoke to dr x at 0900 hrs re: x issue, hung blood at 1100 hrs, pt left for procedure at 1230 & returned at 1400, etc.), i do not remember to chart them. when i'm in a rush, i can go back through my notes, chart them, then cross them out...
when i get to report, though, it totally depends on the nurse. i'm thankful when i'm working with the same nurse from the previous shift. if not, i've starting asking what they like to hear because i've learned that everyone prefers / gives it a little differently.
we use kardexes, and a lot of nurses are still in the habit of reading the pt's name, admit date / reason, dr, etc. it's all there for me, so i ask if they want me to repeat it to them. most say no...
as for other items on the kardex, i let them know if they were completed or changed (i.e., sputum sample send at 1700 hrs & fluids changed to lr @ kvo @ 1300 hrs, etc.).
ultimately, i go in a logical order than works for me - first my head-to-toe assessment with related bits here and there. if i'm doing gu, for example, i'll say if they have a foley then. while i'm talking about gi, i'll say when their last bm was. when i'm talking about skin, i'll talk about whether it's intact or not in addition to their iv site.
i'm absolutely amazed when i see nurses with scribbles all over their kardex, and then proceed to give this completely coherent report. i just can't do that! i have to see everything in order in front of my eyes. (i adapted my current format based on the ones we uses for clinical reports in school.)
in the end, though, when i'm done, i just ask the nurse if i've forgotten anything that's important to her. (just because i prefer to look up labs, for example, rather than have someone tell them to me doesn't mean she does.)
and, when it's all over, i remember that i'm still new at this, and it's going to take some time to get it "right"
Hey, thanks for starting this thread! I work in an ICU so it might be a little different, but here's how we usually do it: (and I'm using this post to help me organize my thoughts as well...I always feel scattered when info overlaps sections of report...and plus my brain is always fried..)
1) Basics:
- name, sex, DOB/age, primary diagnosis
- team following the patient & pager # to beep/name of intern to get orders from
- allergies
- code status
- bugs, and if they're on contact/droplet/airborne precautions
- basic other alerts (i.e. difficult airway precautions, no BP sticks in masectomy affected arm, Hep C + etc.)
2) Medical basics:
- list medical/surgical history
- admit date/reason for admission/primary diagnosis, a chronological narrative about the major events during the course of their stay since admission, & when they came to the ICU
- upcoming procedures/plans for the patient
3) Systems
Neuro
- Mental status (A&O?, confusion?)
- what extremities do they move & how well?
- pupils/gag
Respiratory
- vent settings/type of oxygenation
- trach size/ett size & placement
- breath sound quality
- RR & SpO2
- blood gas results
- special suctioning needs, how often to sxn, what the sputum looks like
CV
- heart rate/rhythm, bp
- access/lines
- pulses? edema? dvt prophylaxis?
- cvps
- tmax & actions taken if febrile
GI/GU
- type of diet/tube feeds
- NGT? PEG? Keofeed? at the target rate? residuals?
- abdomen: distention? tenderness? firmness?
- any BMs? what did it look like?
- continent? foley? rectal bag/tube?
- quality of urine, is urine output >30 every hour?
- net I/Os
Skin
- any wounds? What are we doing for them?
- activity level
- any drains, chest tubes, etc. What & how much are they putting out?
4) Other important stuff (all of these usually get at least mentioned inevitably in systems, which trips me up in report because they sort of need dedicated sections too to make sure i don't miss anything)
Drips
- what drips at what rate, and which are we titrating? and what are our target parameters?
Labs
- anything outstanding? Hct drops? How's the K & Mag? What was repleted? anything that needs to be rechecked on the next shift?
- any results from diagnostics done? (procedures, labs sent, cultures sent)
Stat/PRN Meds given
- how much was given? when (i.e. when can the next person give it)? what was it given for & did it work?
social
- what is the family like/who will be around?
So that's our report in a nutshell. Hope that helps! (this thread is certainly helping me!)
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.
v_deutz
1 Post
I am a new nurse and I am aware that this question is a little old but I wanted any new nurses to be able to use this if wanted. I work on a Med-Surg floor and each morning I give report to a new group of nurses. One wants just the "need to know" and the other stuff (hx,normal labs..) that can be looked up on the chart does not need to be told.Then the other set ask alot of questions and want info. from 3 days ago.So I made this tool to help me try to remember everything.:heartbeat
Giving Report to on-coming shift:
In room _____ we have Mr./Mrs.______________________, a ____ y/o, male/female of Dr.______________ / Consultant's __________________________________________.
Admitted with __________________________________ and Hx of ______________
_______________________________________________________________________.
Code status is: _________. If DNR, is paperwork in chart? Y or N Allergic to ________________________________________.
A&O x___ (name, date, place) Daily wt of _________. IV of _______ at _____ml/hr at the ______________________. Activity level is ____________________________. Dressing changes: ______________. Incision or wounds (loc. & desc.): _____________________________________________________________________.
On 02 at ________. Type: _______. 02 stats: _________% Any breathing tx: ________
_____________________________. Why and what med? _____________________________________________________. Tubes: Foley, ostomy, NGT, suprapubic,JP.
Desc. & amt. of drainage:__________________________________________________.
Last BM:___________ Continent or incontinent of bowel and bladder? Voided how
much? ______________. Diet: _____________. Ate how much of diet? _____________.
Fingersticks are __________ with a sliding scale of _______. Last FS at _____________
was _______ and was covered with _____________. V/S are stable/unstable.
Any abnormal assessment findings? __________________________________________
_______________________________________________________________________.
Pain: pain level of ______ at _______where __________, treated with ______________, response to treatment is ____________________________________________________.
New orders include: ______________________________________________________.
Pertinent labs: WBC_______ H&H_________ K___________ Na_________ Ca______
Trough ________ Peak ________
Next Vanc dose is ______and it is # _______.
Scheduled procedures and/or surgery: _______________________________________.
The plan for this patient is to ______________________________________________
_______________________________________________________________________________________________________________________________________________.
I hope this helps!::redbeathe