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Help with taking/giving report!!

Posted

Hi... I just started my preceptorship (shadowing) on a cardiac floor of of a busy NYC hospital and I'm a month until graduation. One thing I'm not so good at and nervous about having to do is give and take report, but everything else is going well. I get LOST because throughout nursing school I've heard so many nurses give and take report in different ways and it's always so rushed. How did learn and when did you start to feel comfortable? How did you develop your own style?

Thank you! Lauren

Tait, MSN, RN

Specializes in Acute Care Cardiac, Education, Prof Practice. Has 14 years experience.

Basically I give report the way I want to receive report. Brief history of admission, head to toe important points, procedures, last pain meds, anything due to happen procedure wise (e.g. CT/heart cath), patient concerns that need to be addressed (pt wants to talk to doc about XXX, though usually I will put a note on the chart if I can't get that accomplished) and any helpful preferences or heads up (husband aggressive about plan of care, pt withdrawn) etc.

Just keep it on point, clear, and you should be fine :) Also don't be afraid to ask for feedback after a few shifts.

Tait

RNperdiem, RN

Has 14 years experience.

Take a deep breath, now relax.

I like report where you begin at the beginning. Start with "In room 1 we have Mr. Smith. He was admitted on X date with X diagnosis.

Who is this person, why are they here, when they arrived and what they had done? After that, the past medical history.

Beyond that, there are a couple of directions to go.

Some nurses do a rundown on systems: Cardiac, respiratory, neuro, IV access, then issues to be resolved. This is a good way to give a complete report and not miss much.

If the patient is unstable, I run down the list of problems and issues first, then work in the assessment findings.

You develop your own style over time. When you listen to report, take note of the nurses who do it well, and try to follow their lead.

Bedside report gets mixed reviews, but I find that in my unit, it is easier to do a show-and-tell report since I am a visual person and our patients might have 3 surgical drains, 2 chest tubes etc, and it is easier to show than tell.

Just keep it on point, clear, and you should be fine :) Also don't be afraid to ask for feedback after a few shifts.

Tait

Thank you Tait!! I think I need to practice... Maybe to myself or nursing school friends. ;)

Take a deep breath, now relax.

I like report where you begin at the beginning. Start with "In room 1 we have Mr. Smith. He was admitted on X date with X diagnosis.

Who is this person, why are they here, when they arrived and what they had done? After that, the past medical history.

Beyond that, there are a couple of directions to go.

Some nurses do a rundown on systems: Cardiac, respiratory, neuro, IV access, then issues to be resolved. This is a good way to give a complete report and not miss much.

If the patient is unstable, I run down the list of problems and issues first, then work in the assessment findings.

You develop your own style over time. When you listen to report, take note of the nurses who do it well, and try to follow their lead.

Bedside report gets mixed reviews, but I find that in my unit, it is easier to do a show-and-tell report since I am a visual person and our patients might have 3 surgical drains, 2 chest tubes etc, and it is easier to show than tell.

Thank you! Yes... I am a visual person too. That's a problem in the morning because I haven't seen the patients and hearing report on them w/o seeing them first throws me off. I guess I have to learn to get around that. You gave me a good

outline though. I may use it for tomorrow. :}

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

what you need are some good brain sheets to help to keep you organized.....feel free to change them as you need. I ahve collected some and other contributed to be other AN members Daytonite...(rip)

doc.gif mtpmedsurg.doc

doc.gif 1 patient float.doc‎

doc.gif 5 pt. shift.doc‎

doc.gif finalgraduateshiftreport.doc‎

doc.gif horshiftsheet.doc‎

doc.gif report sheet.doc‎

doc.gif day sheet 2 doc.doc

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

what you need are some good brain sheets to help to keep you organized.....feel free to change them as you need. I ahve collected some and other contributed to be other AN members Daytonite...(rip)

Thank you!!!!!! This will help so much! I appreciate it a lot :}

I feel the same way. It seems that like every nurse I give SBAR to wants it done differently. I just start from the beginning like a PP suggested and give pertinent info. Afterwards I just ask the next nurse if there's anything else they'd like to know and then we look it up together. I'm new and have only been on my own for a week so I have just been trying to get pointers from other nurses who I feel do a great job at SBAR.

Racer15, BSN, RN

Specializes in ED. Has 5 years experience.

It gets easy quick. When I did my practicum, I was super nervous about giving report (did practicum in an ED, now work in an ED). This may be repetition from what PP have said, but:

I flip through the chart before I call up. I check to see what the admitting dx is, the doctor they are being admitted to, then I cruise through their labs and jot down any values that are significant, and make a mental note of what labs the nurse may want to know based on the admitting dx. Then I call, give name, age, admitting dx, admitting doctor, why they came in, any known allergies, previous medical history relevant to the current issue, what's going on with them, what interventions have been done, relevant lab values, what their baseline is, any changes they have had, and their most recent set of vitals. I also like to let the nurse know about any extras...is the family difficult, maybe the patient has been kind of demanding, just to give them a heads up and let them know what to expect, and on the flip-side, if the patient has been super sweet and a dream to care for. Then I ask if they have any questions for me. Usually they don't, but some nurses want to know every last detail, others just want the basics. It doesn't take very long to get a method down that works for you.

mmc51264, ADN, BSN, MSN, RN

Specializes in orthopedic; Informatics, diabetes. Has 9 years experience.

We have a cardstock sheet that we fill out in pencil each shift as things change so there is consistency in the report. Is has what procedure, what day hosp/sx; relevant hx, IV details, diet, bandaging, regional, drains, etc and then concerns. It works really well. Try not to worry, you'll find something that works for you.

AJJKRN

Specializes in Medical-Surgical/Float Pool/Stepdown. Has 6+ years experience.

Like Esme12 said, get a good report sheet that works for you. I made mine myself specific to my floor. The only other thing that I can add is to try and read the report sheet in the same order each time so you develop some consistency and confidence as well as being less likely to leave anything important out. Good luck! :wacky: