Published Jun 16, 2015
wheretolook
1 Post
thanks in advance for reading.
as a new graduate, i am having a bit of trouble providing this (what happens next) information to oncoming shift. i know where to find it (roughly). though i do not know what is important or not. i see a long list of progress notes, from the MD, surgeons, social workers, etc... but i have no clue how far to go back or what to tell them. i do not have time to read all of it. advise?
the nurses notes are filled with a bunch of CYA useless information. i tried that already.
Swellz
746 Posts
I look at the primary team's note. Sometimes the plan depends on what several other teams (infectious disease, surgery, med onc) say, or test results, family meeting, etc. You can always ask the team. If I've received bad report, had nothing to go on but illegible MD notes, and can't figure it out based off orders, I just ask. Better than not knowing.
BuckyBadgerRN, ASN, RN
3,520 Posts
Take a cue from the report you are receiving. Is it enough information? Do you find yourself having to go digging for more because what you got in shift change wasn't enough?
Give the kind of report that you want to GET!
HouTx, BSN, MSN, EdD
9,051 Posts
If you do a search here on AN for 'report form' or any similar phrase, you'll unearth some real gems.