How do you give report?

[Jedi_Iatros]

Do you just spit out the highlights or do you report everything about that patient even thought that pt's been in your unit for weeks?

My charge nurse at my other part time job wants just the highlights and changes while certain nurses from the other hospital I work for want to know everything from the age of the pt, mental state, where the IV's located and how much is in the bag, what last narcotic drug was given, I/O's, lab results, etc.

[nialloh, RN]

We give abnormal labs, all troponins, last 2-3 sets of bp's, latest chest xray, main points of CT's + MRI's ect.

[wooh, BSN, RN]

Depends on if the nurse I'm giving report to has had the pt recently. It doesn't matter if the pt's been there for weeks if that nurse hasn't had them, they don't know them. And they could have been there one day, but the nurse I'm giving report to is the one that admitted them, then they know them. If the nurse knows them, just changes. If they don't, I try to give pertinent history, pertinent labs, what got done, what needs to be done, and any knowledge that will help their day go better.

[mobileRN]

Vitals if they are abnormal otherwise I say VSS, then I use a systems approach I always say level of orientation and mobility and then any highlights by system,. Labs highlight the abnormal ones, and what if anything was done to correct that, note what what ones were normal CBC etc so the next RN knows I looked at them. I&O I note if it's close or not. Last pain med given. If in ICU what drips at what rate, same for heparin etc on the units. Progress on DC plans any emotional/family/spiritual issues that came up. Status of IV site and cental lines.

[rpv_rn]

Here is article on shift report:

http://www.findarticles.com/p/articles/mi_qa3689/is_200406/ai_n9425820

[jimthorp]

I give and recieve report by exception unless the oncoming nurse is unfamiliar with the patient.

[MisfonzRN, RN]

I give a short medical history and history of this hospital stay. I then talk about events that happened in the last 24 hours. I go over IV lines and drips. I then go through the assessment and talk about anything abnormal. I also try and mention abnormal labs and what I did about them. I work in a CCU and if the patient is particularly critical or involved (ie lots of equipment, prisma dialysis, drips, balloon pump, etc), we often give report at the bedside so we can go over everything.

[KatieBell]

We do it pretty much like Ms. Fonz. Of course it depends now on which facility I'm at. One, people barely gave report. I had to chase down the nurses for a report, which of course worked out well. Now, at the facility I am at we run down the board with all the nurses present. It helps to have an idea of whatis wrong with all the patients, that way when someone exits the room of a very sick patient asking for help, I go right in because I know that something is probably very wrong with the patient, rather than saying, "We'll send your nurse in" or some such thing!