Giving Report

Perhaps as a performance approval measure you can bring up the use of hand-off communication forms to your charge nurse, educator, coordinator or manager for change of shift. When I give report I sort of go through all the systems. First, who is the patient and when did they arrive or get admitted to the floor. Why are they here (diagnosis and complaining symptoms). Do they have any allergies and are they an isolation patient. What's their important past medical history that may effect their Dx or become a complication. What's their neuro status; is the patient with it? Following commands? Ambulatory? Then cardiac wise: what's their BP and HR like? Are they on telemetry and what rhythm are they? Any PM or ICDs? DVT prophalyxsis? Resp: how are their lung sounds? Is the patient on O2? How have the O2 sats been throughout the day? Is the patients skin intact or are the pressure ulcers? What IV access does the patient have and is the patient on any fluids. Talk about GI/GU: how does the patient void or have a BM (foley, diaper, brp). Is the patient eating; what's their diet. And also list issues that came up through the day like if the patient had a rapid response, fell or had an important procedure completed. Tell the next shift whats expected: the patient needs these labs done during your time or will have these tests done during your time. I know it seems like a lot but once you get yourself into your own rhythm, you'll be fine. Hope this helps and ohhh always remember the ABCs!

Just try to think of the bigger picture, the patient came to the hospital y? What are we currently doing for him? What's the overall plan for this patient (i.e CHF exacerbation plan to continue IV LASIK until can tolerate PO then discharge to skilled nursing) ppl get caught up on the details, which ate important but we can all read progress notes/h&ps, no need to get distracted by their potassium of 3.2 4 days ago

I agree with what the previous individuals have said, it all comes down to getting into a rhythm. The hospital I work for has a printable patient profile that shows everything that the patient is currently prescribed or having done in terms of treatment. I previously used this, but then found that it was much easier to just look it up and write down the important things. I also took it upon myself to create an easy sheet that has all the basics (i.e.; Name, Dx., Hx., Allergies, Abnormal labs, Reminders, I&O, etc.). This has helped tremendously and makes giving report much easier.

Just remember, focus on on the core things: why they are there and what you are doing for them. Practice makes perfect :)

Good luck!

I don't at all like the phrase "giving report." I refer to it as "briefing" since we're briefing the oncoming shift for their duties. At my employer, we brief everyone on the unit's oncoming shift in a conference room. I don't mind briefing the oncoming shift, but I hate being briefed by the offgoing staff. Too many workers want to go talk ad nauseum about individual conversations they had with patients, "cute things" that were said, the substance of their defecation, and any other number of happenings.

When I finally make it to the duty station, I put my census sheet in a drawer with what few notes I've written on it, and I immediately go assess patients. I won't do anything else, other than perhaps resuscitate (LOL), until I'm finished assessing all of them. At that point I'll tend to any immediate needs and then fill out the flow sheet on the EMR. I include two types of assessments seamlessly when I evaluate patients. First, I perform a focused assessment of why they're there, and then I assess to the extent necessary to fill out any remaining fields in the above mentioned flow sheet.

I almost never look at the census sheet again until it's time for me to hold the briefing at which time I may note observations worthy of detailing to the oncoming team.

Are you a new nurse? I feel this is something all new nurses go through. With more experience you will get better. As a new nurse everything seems important. But honestly, I don't care about the freckle on Mr. J's left shoulder that he has had since he was a baby. Try to think of giving report as when they came, why they came, any procedures and by who. Then just give report as if you were doing a shift assessment. Head to foot. Neuro, Resp, Cardio, GI, GU, skin, then go on down checking pulses etc and looking for bed sores. Just keep practicing! ?