hand off reporting... and patient researching.

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is there a rule of thumb i am supposed to follow when giving report to the next shift? for example, i have a patient that has been there for 2+ weeks... how far back do i go? i have:

discharge plans

physician notes

consultations

procedures (surgeries, x-rays, etc...) done

i just came on shift and i need to give report to the oncoming shift. as a new nurse, i tried to just repeat what the previous nurse stated and any changes on my shift... though some nurses want the entire (2+ week) history on the patient. and really have a fit about it.

also, DO YOU SET ASIDE TIME TO "DO RESEARCH" on your patient? the other day, i (myself) even failed to read MD NOTES and i missed something that got me into a world of trouble. (i do not have a CNA/LVN to delegate anything to. the acuity on the floor is high. i do not always have time for this.) this information was not disclosed to me during handoff, either... even though I SPECIFICALLY asked. being a seasoned (10+ year RN) i took them for their word. i am not placing blame on anybody, but i would like to keep myself off the **** list and my patients safe. how do i prioritize RESEARCHING my patients?

thanks for the help~!

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Specializes in Medical and general practice now LTC.

Personally I would want to know the last 24 hours. If I want more then it is up to me to research what I want to know. Unrealistic going back 2 weeks especially as at the end of a shift you have worked long enough and want to get home

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Agree with Silverdragon. Last 24 hours is enough for me. In fact if you try to give me the rundown of the last 2 weeks I will probably cut you off. Heh.

It is irritating and unrealistic for others to expect that much info from you. I suggest saying, "I don't have that information, you should be able to find it in the chart."

You have now learned not to accept what you get in report at face value. Throughout your shift you should be verifying your information not only for yourself but so that you are passing on accurate information.

As for research, I find that the quickest way to get a good picture of the patient's hospital course is to read the most recent MD progress note. This should have older info copy and pasted back from time of admit all the way to the present plan of care.

When time allows, read the ED provider's note, H&P, and any consult notes. Also review CT/XR/MRI results as well as labs, noting trends.

Lastly, please know that some shifts it will be all you can do to stay afloat and you may not have time to gather all the information you want. Give the best report you can and let it go.

If the oncoming nurse is annoyed that you're not spoon-feeding the chart to her, it's really not your problem. Personally I would rather look things up myself, but I know not everyone is like that.

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how much time should i allocate to this? what is adequate? i have a 1:5 patient ratio. also, is this legal, if i do this on my break?

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