Giving Report

I start out with giving the history of the patient, what brought them to hospital, then what brought them to icu, and any further issues/procedures they had while in ICU. Then after that, I start with CNS, CVS, RESP, GI , GU, skin/wounds, IV's and fluids running and boluses given, then Labs. You can make your self a report sheet with the above info and add extra stuff like a spot for vent settings, what the blood sugars were, tube feeds, vital signs, ect, any thing that pertains to the patient so you can just fill in the blanks after. the report sheet I made is the size of half a sheet of paper and has everything on there that would pertain to an ICU patient and I just fill in the blanks after I do my assesment. Its pretty fool proof. As long as you go by system you shouldnt miss anything.

I reserve a section of my "brain" sheet to jot notes for report as I go along throughout the day. I start filling it in as I take report at the beginning if the shift. Does the pt have a PICC? A foley? Telemetry? Med or food allergies? An unusual lab result, important lab draw scheduled for the next shift or scheduled fingersticks for blood sugars? If I give a PRN med during my shift, that gets put down on my time along with response. Also any procedures or consults on my time.Toward the end of the shift I look it over to kind of tie everything together and see if I need to look anything up or recheck anything but this way I get the big picture put into writing while fresh in my mind.

I suggest so that you can give a good report with all the stuff the other posters have mentioned you start with getting on the computer and making a customized work sheet for yourself........one that is special to where you work......I did this when I was on med/resp and found in invaluable......I did have MANY versions until I found it was exactly what I needed with the right space for each item, etc.

You can do it on excel or word...whatever. But that is what I had to have to work.........also helpful was to make many copies on colored paper--easier to keep track of--especially when they get left in a chart or something.....I kept lots of copies in my mailbox on the unit. Let me know if you need help getting started....I would be happy to help.

I agree with above- chief complaint/admission diagnosis --> history --> code status, allergies --> procedures --> review of systems (CV, RESP, GI/GU, NEURO, SKIN/Musculoskel, IVs access/drips) --> serial labs/nsg interventions? --> additional needs... I like to have the pt's ICU flowsheet handy and a kardex if need be. On our unit we like to briefly go over the last 12 hrs of orders for the pt to show the oncoming nrs what was ordered, done, or still may need to be done (so nothing slips through the cracks). I agree with making your own "report sheet" to help organize your thoughts starting out - jot down notes during your shift so you dont forget when giving report.

I am a visual person. I have the cardex/flowsheet/ medex in front of me. I often do a verbal and a "show and tell" report.

The verbal explains who the patient is , why there are here, when they had surgery done and past medical history.

Then I go over vitals, assessments, and current issues.

For the show and tell part, I take the ongoing nurse into the room and go over infusions, check the dressing, demonstrate where the doppler pulses are and show where the lines are.

I find having visual aids keeps me from forgetting to mention important things.

i always do my report the same way...

1.) name, age, allergies, pmh, the team thats following them and the name and pager of the resident on call.

2.) reason for this admission, quick run down of the hospital course and if i had a busy day, quick run down of that as well. ie - c/o "worst headache in his life" after a fall at home, initial ct showed a SDH and a SAH, no midline shift, had xyz neuro changes - repeat ct after that showed xyz, trouble weaning sedation for a week, eventually trached on xyz date, had some neuro changes today, did a repeat ct, it showed xyz, now our plan is xyz."

3.) systems specific report.

psych/soc - family, issues, passwords, expectations, issues, s/w needs, etc...

neuro - full exam, an variations, sedation and pain

cv - vitals, profusion, lines, gtts, labs

skin - any wounds, pressure ulcers, dressings, drains, etc...

resp - airway equipt - trach, ett, etc... vent settings, sats, lung sounds, secretions, abg

gi - tf/ivf/tpn, bowel sounds, last bm, blood sugars, general appearance, nausea, ngt, gastric access, etc...

gu - urine output, color, consistency, labs.

after that, all orders placed that day, what was done, what may need to be done, show them that all the meds on the mar are up to date, review gtts at bedside, have already re-ordered refills on the gtts and have a fresh bag of ivf hanging next to the one infusing, offer a turn before i leave so the on coming nurse can check the skin before i leave.

its thorough, but you cover all your bases! then i always drop a quick note in saying that everything was reviewed, gtts re-orders, meds up to date, labs pending, etc... and all oncoming rn's questions answered after reviewing pt with the oncoming shift. :)

cya.

I get alot of compliments on my reports. There is nothing worse then listening to a jumbled, all over the place report. I have a full page "brain" for each patient. I have each system on that paper according to our charting, for example Neuro is first. On that paper I give myself plenty of room to write down everything according to that system such as labs, tests, etc. That way, I go right down my paper and tell what happened with that system. For example, GI: diet, bm's what happened with the colonoscopy, how they take their pills, if we still need stool samples, labs etc. If there is a system that is normal, I state that and move on. It keeps me very organized, and give report in a quick, detailed fashion.

Doris

I made my own report sheet that I use. I usually write the report that I receive in black, and add my assessment and updates in red. I make a double sided copy, so I don't have a bunch of papers in my pocket...one side for each patient. I'm going to try to attach a copy for anyone to use...if it doesn't work, send me a message and I can email it to you. I hope this helps!

ICU_Report_Sheet.doc

Here's the one I use...

reportsheet.doc

The report is now called 'SBAR' -Situation,Background,Assessment, Recommendations-that's how your report should flow to anyone involved in your patient care and is now required for Joint Commission. Since we are in a critical care forum, SBAR is expected from you and is being encouraged. It just keeps you focused on what is important.

eliza

I'm usually the one that hates acronyms but I think ISBAR is a good one. Identify: the need to give reort to a colleague a doctor, whoever.

Situation: change of shift, pt gone bad, what you are actually calling about or who you are caring for.

Background: Just the facts maa'm!, history of present illness, what makes this call or report so important.

Assessment: We can't care for what we don't know! Vitals, uop, readings, monitor, meds, gtts...you be the judge!

Recommendations: I love this one...what you want or need to care for this pt. Don't sugar coat it and don't waste yours, the pt or the md's time.

Giving report and calling an MD are stressful but meaningful learning ops! As the doc afterwards what he likes to hear and your colleagues! Go getem!