How to get a good report from previous shift?

neutrophil · May 14, 2010

I have no idea, I got report only about the problem patients, but when I read the log, there was a patient that was marked "stable." Hello, the patient had been dead for approximately a week.

I was giving my meds, there was a new order for "Duoneb," you need a pump and tubing with a mask or mouth piece for this treatment. It was signed off at 0900, 1300, ordered qid, when I went to give it. There was no pump, nothing. Hmm, how did they give it.

There are honest mistakes that we can all make, there are mistakes out of laziness or whatever reason. How do you fix it? I don't know.

Possibly meetings that don't identify people but acknowledge that the problem exists and that write ups and terminations will occur. Inservices that address this problem. One thing is sure, the patient needs to be taken care of, we are their advocates.

JulesRN10 · May 14, 2010

I am a float nurse, so I use a float sheet every day, no matter what floor I'm on. This way, I know I haven't missed anything pertinent.

Many of the floors I work on went to using this system-it gives us continuity of care. We all give the same info, and it cuts down on report time, giving unnecessary info instead of what we need.

Might be something to look into, creating your own sheet, so everyone can tell what needs to be told; especially, if you haven't been nursing that long.

Reigen · May 14, 2010

I am having a bit of trouble lately getting a good report from the 7-3 nurse. She is just as new as I am, only nursing since March, and there are days when she gives report and then I find out all these pertinent pieces of info along the way. Ex. got report, we actually walked up the hallway to each room. She states so and so is good, nothing new. Well, when I went to give so and so his meds, I couldn't find him. He doesn't smoke, he's not outside, I was starting to panic although he isn't a elopement risk. Then one of the cna's who was working a double says ,"oh yeah, he went to the VA today for dr. visit and has't come back." Oh, might have been nice to know. and every day there has been some important piece of info I have missed. Some days there is nothing written on report paper and it's "Everyone is good" come to find out one started on ABT for UTI, etc. Anyone have any suggestions on how to go about this?

From your post I think I understand you might work in a LTC setting, rather than Acute Care?

The next time you get/take report from this particular nurse, I would have a list of questions...Has anyone started any new medications or treatments? Are there any incidents that I need to follow up on? Are there any outstanding labs that needs to be reported to the physician for follow up? Are there any patients/Residents that have appointments with outside providers? Has anyone already left for an appointment?

Hope this helps

TonyaM73, ASN, RN · May 14, 2010

Learn to ask the right questions.

I always ask:

1. any extra equipment for this pt ex. foley, O2, nebs, IV ect.

2. blood sugars

3. Coumadin and if so what was the PT/INR

4. Wounds

5. Appetite

6. last BM

7. Antibiotic therapy and for what

8. What is their admitting diagnosis

9. Any narcs that I should be aware of

I'm sure that you can come up with other questions as well. If you get into the routine of asking these questions, then you can get a good picture of what is going on with your pt and you won't feel so lost. If the nurse does not know the answers to these questions, then you both can look them up while she is still there. If you start asking these questions, then she will start to realize that she needs to have these answers before you get there and it will make her a better nurse as well. I have had to learn this the hard way and have tried to find these answers before the oncoming nurse comes in. Always ask gently though, not like you are trying to trip her up and it will go over a lot better. I have had both kinds of nurses follow me when I was new and the one that was kind and would help me find the answers to the questions, was the one that I really wanted to have the answers for the next time. The one that would just fire off questions and act like a snot, I thought that if I have time, I will look it up and if not then you can do it yourself. Good luck! It will get better.

CT Pixie, BSN, RN · May 14, 2010

I was having the same problem with shift report. I'd only get 1/2 the picture during report. When I looked at our 24 hr reports, there were things on there that weren't relayed to me.

Now what I do is, get report, the walk over to the 24 hr report to see if anyone is on there that wasn't reported to me, I pull a BM list to see who I have to give Milk of Mag/Supp/Enema too, and luckily we are computerized so I then pull and print out a 72 hr report that allows me to see ALL charting done on any resident in the past 72 hrs. Usually that alleviates any "missing" info that wasn't passed on.

CoffeeRTC, BSN, RN · May 14, 2010

If she is new just like you, mabye you can have a talk with her about what you need for your report.

I always ask my questions too. I don't work ft, so things might have been missed or not reported to me because they are not new. I will ask if anyone has any labwork that needs followed up, any new meds, any pain issues etc.

I also get to work a few minutes early and read the report for the last few days.

After you get report, walk around and do a general head count and look see on your residents.

Nurse_Tricia, LPN · May 14, 2010

thank you all for responding before i head on in to my next shift in 2 hrs. I do work in LTC. The float sheet is great, I think it is probably for Acute care setting as I think it would take me a while to cover 30 patients. But I did take some pertinent info from it. I think the asking the questions about any new on ABT, etc is probably the best to maybe jar her memory. I am one that probably gives too much info, not a book, but I can see the night nurses like ,"really??? really??? oh, ok ." LOL. But I feel it is important if they have a small amt. of swelling in ankles and esp. if the residents son brought it to my attn.

Thank you all again!!!! I just love this site.. I feel it enhances my ability to become the best nurse I can be!!!!!

fiveofpeep · May 14, 2010

when I do report at the bedside, as a new nurse I often remember more and give a better report. maybe you can do this too?

willsgirl · May 14, 2010

You may also want to give your report sheet/list of questions to the nurse your receiving report from. This may help her focus/steamline her report to you. She won't have to scramble to answer questions because she will anticipate what your going to ask her.

crbetts · May 14, 2010

I am a nursing student, and the attached sheet is just what I've been looking for! Thanks a million for that!

NotFlo · May 16, 2010

Report in LTC is a funny thing. It's easy to give way too much information, and it's also easy to give no information. Some nurses seem to have a real knack and talent for talking for an hour and conveying almost no pertinent information :lol2: .

All my pts. are rehab pts, so we have frequent discharges, admissions and order changes to deal with. Most nurses at my place tape report whenever possible.

I always look at the schedule and report based on who is coming on. If it's someone who has these pts on second shift for the past 5 days in a row I know I can just update on any changes or new orders. If it's someone new, or a per diem, etc. I know to include more information.

I just had a new grad orientee and she was having a hard time remembering what to include in report. I had her make a list of what she wanted to say for each patient and that helped a lot.

Another thing is regardless of the report I get I always check the 24 hour report, the doctor's board and the list of who has MD appts, discharges and labs due that day as soon as I get in.