Published Jan 14, 2006
cksl
19 Posts
what do you take note when the nurses are passing over report?
what do you think is the best way for a student nurse to learn during clinicals?
Daytonite, BSN, RN
1 Article; 14,604 Posts
I want to know about any very special orders (such as if the patient is NPO, on absolute bedrest, needs to be turned every 2 hours, or on some special diet). I want the other nurse to tell me what happened with the patient during their time with them. Tell me the results of any labwork, x-rays or other tests that were done, if they know them. If the patient is a diabetic I want to know what their blood sugars were and when they were done. If the patient had surgery or the doctor did some procedure on the patient I want to know about it. If the other nurse had to contact the doctor, I would like to know why and what the doctor ordered, or if he changed any orders. I want to know if there has been any new medication added to, or medications deleted from, the patient's list of medicines. I also want to know if there were any significant complaints or problems that came up that the previous nurse had to deal with and the outcome. I want to be told if there is anything I need to follow up on after the other nurse has left, rather than have to find out about it myself when it is too late.
When I was a new nurse, I made a list of items, like the above, to report on during shift report, what you are calling handover report, in what I thought was an order of importance. I kept that list in front of me as I gave my report to the next nurse who would be following me. You might want to do something similar to help you organize your report as well.
I'm attaching a copy of the report sheet I use when I take report as I come onto my shift. I can fit the information for 6 patients on one side of the sheet. I will refer to it when giving report as I tend to write down all kinds of information on it over the course of my shift. Here is the United States it is common practice for us nurses to start one of these sheets every time we start a work shift. It is to help us keep organized and remember the important things we have to get done for each of patients we are assigned to. Sometimes the hospital supplies us with these sheets. Sometimes, like with myself, a nurse makes up her own sheets. The file I have attached contains the report sheet that I use. I created myself on the computer a long time ago. I have changed it often over the years and will change it whenever I think of a way to improve it so that it accommodates my needs. I am happy to share it with you. The boxes in the top left of each of the six large rows are for the room number (or bed number) that the patient is in. The open spaces are where I write down the things the other nurses have told me during the handover report. I also will write information on this as I go through my work day. You will see that I have certain information that I will want to gather on patients (blood sugar results, vital signs, intact and output). As you can see, we have a lot of patients who have diabetes. If a patient does not have diabetes, then I do not have to fill that information in. I also like to know what their IV orders are so I don't have to keep checking the doctor's orders in the chart. I either keep this piece of paper folded up in the pocket of my uniform so I can take it out whenever I need it, or I will put it on a clipboard that I carry around with me during my work day.
I hope you find this helpful.
A student nurse learns best by not only watching other nurses, but by also volunteering to do things with patients. You cannot learn by watching. You must also do things so you get experience.