How to give report?

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Specializes in Med-surg.

I am a GN and now am orienting on midnights (which surprisingly I like lol since I have never worked midnights). I guess I am nervous about a lot of things, but I try not to show it. One area I feel like I am lacking in is report. Usually my preceptors do it, but I try to say comments in between report (so it looks like I am trying). I just get so nervous and frustrated inside because I feel so incompetent. I am still trying to remember what the nurse before us said about the whole patient (which I do write things down), but sometimes I feel like more is said than needed. I guess I want to be more like "here are the facts that are important" and I don't want say stuff that isn't important. So any suggestions / stories of starting out please? :nurse:

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Don't worry about too much. As you gain experience you will start to weed out the unnecessary automatically. Listen to others give report to see what they include and ask questions of your preceptors. That is the only way to learn how it is done at that facility. Best of luck to you in your new job.

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We use a DATAS report format: D - Patient's demographic (name, age, sex, where they come from - LTC or home), A - Assessment/allergies (I go through mine sort of head-to-toe: neurological, respiratory, cardiac, GI, mobility, GU, skin, IV access, diet, pain), T - Tests and test/lab results (if they have been an inpatient for a long time, I go with the most recent and/or pertinent tests), A - Alerts (Are they DNR? Confidential patient? Fall risk?), S - Status/discharge planning. Then at the end you can fill in the little details you might have missed during the rest, but I find that with this, most everything gets included.

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The type of report you give depends alot on the assignments. If a nurse has had the same patients for several days, she may not need to know things that happened a few days ago. Ask the oncoming nurse if they are familiar with the pts you have had, and take it from there. Congrats on the new job and good luck.

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Specializes in Hospice.

Im a new grad to. i have been doing reports since nursing school since i was on a one on one preceptor model...so this is probably where i am most comfortable..... What one preceptor in school had me do that really added to that comfort and i do a mini version of it now is set five to 10 minutes aside if you can to formulate your thoughts and 'practice' . The more i do that the more less daunting it is. you also learn by the questions you get what should just be 'standard' in your report. you will get it , dive in there while you have someone to critique you

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We use a DATAS report format: D - Patient's demographic (name, age, sex, where they come from - LTC or home), A - Assessment/allergies (I go through mine sort of head-to-toe: neurological, respiratory, cardiac, GI, mobility, GU, skin, IV access, diet, pain), T - Tests and test/lab results (if they have been an inpatient for a long time, I go with the most recent and/or pertinent tests), A - Alerts (Are they DNR? Confidential patient? Fall risk?), S - Status/discharge planning. Then at the end you can fill in the little details you might have missed during the rest, but I find that with this, most everything gets included.

LOL~ now you will all know what a geek i am~ I have been worried about this subject myself, and havent even gotten a job yet. So after reading this post I have made myself a cheat sheat chart to jot which info i will need for report! I sure hope i get a job soon, so i can use it!!!

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Specializes in Med/Surg/Tele/Onc.
We use a DATAS report format: D - Patient's demographic (name, age, sex, where they come from - LTC or home), A - Assessment/allergies (I go through mine sort of head-to-toe: neurological, respiratory, cardiac, GI, mobility, GU, skin, IV access, diet, pain), T - Tests and test/lab results (if they have been an inpatient for a long time, I go with the most recent and/or pertinent tests), A - Alerts (Are they DNR? Confidential patient? Fall risk?), S - Status/discharge planning. Then at the end you can fill in the little details you might have missed during the rest, but I find that with this, most everything gets included.

I really like this. But where do you put history?

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Specializes in Med-surg.

Thank you guys for your input! :) I am going to see how that DATAS format works for me tonight. I am doing 3 12's in a row :uhoh3: startin' today!

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Specializes in Psych ICU, addictions.

You really will get better as time goes on. When I first started I included every little thing including a lot of unnecessary stuff. I usually gave report to the same two nurses (which one depended on which shift I worked) and they helped me learn how to streamline my report so it's concise but still passes on the important info.

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Specializes in CHF/RENAL.

Also a new nurse. (1 yr) We use something very similar to the datas report format. Ours contains the pt history after the admitting diagnosis. We update it once a shift but keep a copy for our use during the shift as a guide. I write down new info or changes in a different color ink, which helps me remember to pass it along to the next nurse, such as significant change in bloodpressure

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Specializes in Med/Surg/Tele/Onc.

Can someone explain (give an example) of how you use SBAR for giving report to oncoming shift? Using it to call a doctor to report a change, critical lab, ask for something I get. Using it for report feels to me like putting a square peg in a round hole.

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Specializes in CVICU, telemetry.

Report Sheet for General Medsurg/Tele

1) Name

2) Age

3) Code Status

4) Allergies

5) Primary Physician and or Teams involved

6) Chief Complaint and Diagnosis

7) *Pertinent* Medical Hx

8) Isolation for Contact, Droplet, etc.

Extremely brief, succint narrative of course of day: ("Patient's major issue today was increasing respiratory failure as AEB tachypnea, desats, increased 02 needs. We did a CXR, found her lungs to be wet, gave her 20mg of lasix X1, put her on biPAP and gave her albuterol tx with increased 02 sats, gave.5 ativan IVP for anxiety with good effect. Decreased tachypnea post intervention, but she is still on close resp. watch.")

*Focused* Review of Systems (Often contains narrative components). (Not all of these will apply to all situations--feel free to add or subtract given your specialty).

Neuro: Mental status, orientation. BUE grips/strength, BLE plantar/dorsiflexion. Any hemiparesis or gait issues? Need for assistive devices for ambulation or hearing, sight? Any acute mental status deviation from baseline. Time and dosage of last pain meds if given. Restrained? If so, when is the order expiring?

Cardiac: Temp and source (oral, axillary, core, rectal, etc). Rate, rhythm, arrhythmias, heart sounds, peripheral edema, peripheral pulses, pertinent labs (K, Ca, Mg, Bun/Cr). Repletion of electrolytes if done.

Respiratory: RR, adventitious sounds, O2 therapy if any, 02 sats on same. Resp. therapy tx's and time of last tx.

GI/GU: Abd inspection, bowel sounds, NPO or diet status; swallow status; aspiration precautions. Any n/v/d? If so, how treated? Dentures if any. OGT if placed. If tube feed, is it by OG/NGT? Formula, rate, H20 flushes, residuals if any.

GU: color, appearance, any odor. Foley or other indwelling device. Void amt per hour or shift. If HD patient, HD schedule, last HD date, plans for further HD, whether or not patient is anuric. AVF's, which arm if present.

Skin: Gen assessment, abnormal findings, dsg changes.

Psych/social: Family, SW issues.

Labs values (esp if abnormal).

--electrolytes, cultures,

Test Results/Pending Results

CXRs

CT scans

MRIs

etc,

Lines:

Peripheral lines

Central lines

Porta caths

HD catheters

IV drips--

type and rate

Misc:

Timing of any pertinent med given or due.

Procedures due/done.

Plan of care:

1)Go over shift orders together!

2) What is/are the *immediate* primary need(s)/intervention(s) for this patient, by priority? (ex: draw PTT for heparin titration @ 0800, preop checklist needs to be completed, pending procedure teaching).

3) General trajectory of care: What are we hoping to accomplish/which systems need closest monitoring (ex: resp. watch for desats and increased O2 needs, pulmonary toilet, etc, V/Q scan for PE).

4) Ask: "Any questions?"

-

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