Giving Report

bluegeegoo2, LPN · Feb 16, 2015

Generally speaking, you hit the "high points" i.e. acute changes in condition, new meds, med changes, increase/decrease in ADL care, etc. We have a 24hr report sheet that we fill out so that changes can be documented for quick reference for the on-coming shift. Nights starts the new 24hr report so that there is a new one every day. Several days worth are kept on the clipboard so if someone has been off for a couple days, they can flip through and get an idea of what's been going on in their absence.

Also, don't worry too much if you don't have all of the answers the next shift is looking for. They are perfectly capable of looking up that information for themselves.

4boysmama · Feb 17, 2015

I agree with the poster above. One of the things that drives me nuts on my sub-acute rehab unit is when the nurse giving report has no idea WHY the pt is with us. I'm not expecting a laundry list of past medical history; but not being able to tell me the admitting diagnosis for why they are in our facility is really unacceptable. Things I always pass off in report: admitting diagnosis, code status, allergies, if they've been to therapy/info from therapist during my shift, any new orders obtained during my shift, any pending labs/tests, if they were out of the facility during my shift/expected to go out on the upcoming shift, any problems they are currently experiencing, and (if they are diabetic) what their BG and coverages were on my shift.

NutmeggeRN, BSN · Feb 17, 2015

Poop...Its all about the poop in my facility!!! Best know what the poop status is, or else!!! OK It is important, as they can become constipated or you can exacerbate a code brown!

CT Pixie, BSN, RN · Feb 17, 2015

I have worked in LTC for years. I had the same patients day in and day out as did the nurses I was relieving and those relieving me. We had our assigned floor/unit/patients all the time so we knew them pretty well. So when I was getting report on those patients, I really only needed the basics. I didn't need their code status, allergies, PHM, etc. I just needed what was 'new' or 'different' for them.

for example..if Mrs Smiths baseline was normally confused, I didn't need it said in report that Mrs Smith was confused..she always was. However if she was a lot more confused than normal or if she was having new issues (violence, yelling out, etc) that I'd want to know.

If Mr Smith was never confused, I want to know if he was during the shifts before me.

If anyone hadn't had a BM in X amount of days, I needed to know that (although I would also check the BM list myself to double check who needed the BM protocol started (MOM, suppository, enema etc).

Any new orders or changed orders should be reported, any new labs that weren't in normal range, a code status change, if somene had some new symptoms that suggested something new was brewing such as more tired than normal with a congested cough and sneezing...

If it were a NEW patient to the unit, I'd need the run down. Are the independent, assist x1 or 2, walker/cane/wheelchair, pills whole/crushed/one at a time, code status, baseline mention, quick PHM, allergies etc

lumbarpain, ADN, RN · Feb 18, 2015

when you are working with basically the same nurses from days to nights....you would think there would be some kind of routine to reporting, I have had one Nancy nurse tell me to skip over things she didn't want to hear....no blood sugars etc...sorry..blood sugars to me are important...so are vitals..ABT, falls, changes in behavior. changes in meds. ADLS..PT/OT changes....or any other type of important information ALL SHIFTS should know...however....there is NO round robin at my facility..most of the nurses are haphazard and just don't care....they leave for the day when an admission is halfway done...and other things that should be completed IF YOU STARTED IT..please finish it IF AT ALL POSSIBLE...if I were to get an admit..I would never leave it for the night nurse to complete....and report is a joke.....many things I have to find out for myself..or through family members..the patient themselves..or from the Aide grapevine.....communication is the worst in these facilities....the worst....this is why I wanted to leave this job many years ago,

CoffeeRTC, BSN, RN · Mar 6, 2015

Depends on if you've had the pts before or not.

New pts....why are they here?, top diagnosis, LOC/ orrientation, pills whole or crushed, diabetic or not, IVs, changes in orders any wounds?

extras....cont or incont, ambulation status, family issues.

CapeCodMermaid, RN · Mar 7, 2015

One thing I always passed along in report was the last time I had given the patient pain meds, when the next IV needed to be hung, any falls, and anything out of the ordinary. I'd try to give as much pertinent info on new admissions....major diagnoses for sure and any new med orders.