Giving Report

[BoyNamedSue]

Hey everyone, my first post. I recently started working at a LTC facility as my first position out of nursing school. I'm having trouble giving report. I got ripped by another RN for not saying how a new admit ambulates, and this really made want to get better. My questions, what should be included in a report, and any tips on getting better? I've been organizing my patient sheet with vital signs and assessment data; however, I seem to forget info such as if a patient has an appointment coming up, how much she ate at supper, or how he transfers. Any help is appreciated - right now I feel swamped with paperwork, patients, and charting.

[Sassy5d]

Give report how you would want it.

When I worked ltc, especially agency. I wanted to know code status, how they took their meds, orientation, how they transfer, how they acted during the last shift, any vitals obtained, new orders and last glucose obtained and time.

Usually when I worked ltc, report was quick because I already knew the person n I just needed any changes. Like they have uti and are on cipro, etc.

[CapeCodMermaid, RN]

My nurses do walking rounds. They report on any vital signs out of the norm, any new medications, any falls or other incidents, abnormal labs, and any new admissions on the unit. They certainly don't have time to tell the oncoming nurse how much the resident ate at a particular meal....unless that resident is newly on Megace or has had an increase in Remeron. Quite often, they might not know how a new patient transfers if the new patient just arrived.

Some nurses expect report on everything...they need to take responsibility for looking up information they think they need.

[amoLucia]

To CCM - your last sentence says it all!!!!!!

To OP -I've worked with some nurses who ALWAYS seemed to ask the ONE question I just didn't have an answer for. Made me feel DUMBER than dirt! Just seemed to zing me. And I've been working since the Dark Ages.

Took me a while to figure out that question had not been critical to my delivery of care. Then I would consider WHO was asking the question. One gal I worked with was really on target but then my chewed chewing gum had more smarts than another nurse I worked with.

You'll never please everyone - just do your best.

[BahoRN]

I always give my report as to what I think is pertinent, and then I finish by asking the oncoming nurse "Is there anything I missed or do you have any questions for me?"

This avoids any ego issues on their part.

[BahoRN]

Here is a form I used when I was a new nurse. It really helped to organize the info and provide sense to my reports. Hope it helps you!

Patient Data Forms.doc

[nurse_w91]

Here is a form I used when I was a new nurse. It really helped to organize the info and provide sense to my reports. Hope it helps you!

[ATTACH]14242[/ATTACH]

I was trying to look at your form but it doesnt open. Im new in an ltc, i start on monday and im afraid im going to mess it up

[BahoRN]

I've sent you my email in a private message to you. You can email me and I will send it over if you like.

[ktwlpn, LPN]

Back her off, don't let her interrupt you. If you are like me that just throws you of track. She is trying to intimidate you. If she interrupts tell her you are going to continue on track and she can ask any questions when you are finished.

[Gabby-RN]

My report would go something like this: patient is full code, alert oriented x3, vss, dx of htn, chf, sleep apnea, uti, ambulates independently with a walker, regular diet thin liquids -good appetite, Cpap at bedtime, receiving abx bid for uti, continent of bowel and bladder, large formed BM this shift, patient has appt tomorrow with cardiologist pickup time is 8am, paperwork is all set for appointment and transportation is booked, patient needs am meds prior to leaving. New orders today for saline eye drops q4h prn s/t patient complaining of dry eyes, otherwise patient had a good day...any questions?

I would have my report sheet set up so. I could just look at it and everything would flow in this order for every patient.

[casi, ASN, RN]

I'm wondering if Baho and Gabby work the same kind of LTC that I do. When you have 20-50 patients you can't give a detailed report on each one. You also don't need a detailed report/assessment sheet on each person. Each facility I've worked has a report sheet that has a list of all the residents and normally has very basic info like if they are diabetic, or on hospice, if they are on thickened liquids, how they take their pills, etc. When I take report I write my report on this sheet in red, and then through my shift I write vitals, PRNs, and anything I need to pass on in black.

What I normally give in report: Anything abnormal such as vitals, behaviors, labs, acute illnesses, any contact with NP/MD(I work nights, so if I've got a NP on the phone it's for a good reason.). Any PRN medications given and time they were given. If there is an early appointment that I was told about during PM shift report, I'll pass that along.

For new admits I try to give a full run down of the patient. Let the oncoming nurse know if they are A&O, how they take their pills, if I know how they transfer/move I'll pass that along, any family issues, patient preferences, primary dx.

Thinks like intake & output, how they ambulate, upcoming appointments are documented and easily accessible. I would expect that the oncoming nurses would look at this information before starting their day if it was something that they needed to know.

[smartnurse1982]

Wow,i have never worked in facilities like these!

We usually had report sheets,and it was only for pts that had something pertinent going on like Abt,falls,new admits,etc.

If they were npo,on thickened liquids,etc...that info should be on the MAR!