How do you give report?

[ama3t]

I was reading a post about nurses coming to report with a blank paper and not knowing anything about the pt they were getting. This is so entirely different that what we do, so I'm curious what all methods people use.

I've seen some places that give you forms to fill out as you go through report, to make sure you don't miss any questions, but I love what my hospital does.

We get a printout on all of our assignments. It includes Name, DOB, a small portion of the most recent progress note so we know why they are there, their medical hx, allergies, access, and all current orders divide into Medications, Treatments, Respiratory, Diet, Labs, and Imaging/Procedures scheduled. Its really nice because we have the situation and background right in front of us, without having to write it all down. We still discuss this in report, but it leaves more time to talk about assessment, especially if the oncoming nurse is early and reads through it before report, which a good portion of our nurses do.

Does anyone else use something like this?

[RN403, BSN, RN]

That sounds like a great idea. Getting a print-out like that would be oh so helpful. We have report forms that we fill out as the off-going nurse rattles off their assessment findings, labs, tests, etc. I also bring my computer with me when I get report so that I have the patient's overview sheet and orders up on the screen that I can take a quick glance at.

[PacoUSA, BSN, RN]

I made up my own brain sheet, I think that's best. But now I have a new job and I think I will have to change it.

[atran4284]

Make a paper for each pt on blank printer paper.

N

Draw a heart

L

G

G

Lines

Skin

Tx:

Labs:

Neuro

Heart

Lungs

GI

GU

Lines-ng-tubes, iv, pic

skin

TX- what are you doing for the pt, abx theapy, neruo checks, acu checks

Labs- whatever is pertaining to diagnosis and treatment

[inchii]

The assignment printout sounds great, but I still prefer the report sheet that I made. It makes me more organized when getting/giving reports. I like just having a single sheet and my clipboard for all my patients. My handwriting is very small, I fit 4 patients in the front of the sheet, then if I fold it crosswise, I can add more patients at the back.

[Momma1RN, MSN, RN, APRN]

We get a print out of demographics and then current orders including tests/diet/ etc. It also includes vital signs and labs that are in the system. When I give report I start with name, age, admitting dx, allergies, precautions and then go into chief complaint, brief course of stay, and then go into the systems.

[Momma1RN, MSN, RN, APRN]

I will add that we are moving to EPIC soon, so i'm sure it will all change soon.... We are still expected to give report in SBAR format.