How do I give better reports?

NurseLife329 · Sep 10, 2012

The unit probably has some kid of report tool or sheet with the most important info about each patient like diagnosis code status, labs, diet, etc that's what we use on my unit it works well and keeps report from getting lengthy

amarilla, RN · Sep 10, 2012

I agree - most units have some sort of report sheet, kardex or SBAR format document that they use to organize patient information. When you get to the unit, it might be helpful to keep your eyes open while you're getting report and see if there is a particular form they're using. If you see that your nurse is using a specific form, ask your clinical instructor (or the nurse herself when she has a moment) if you may copy a blank form to help you organize your information for post-clinical discussion. In the meantime, a simple google search for 'sbar form' or 'nurse report sheet' can give you a starting point.

My own advice: students want/need to know everything and all that information becomes overwhelming and wordy. You want your report to paint a clinical picture:

who is this patient? (name/initials, age, gender)

why are they here? (admit date, chief complaint)

what is their history? (medical/surgical history)

what has happened since they were admitted? (succinct summary of clinical events since admission)

(briefly) what is the plan for this patient? (any ongoing issues, discharge planning needs)

That is just my opinion, of course. Tailor the above to what your post-clinical conference requires and perhaps ask the instructor for pointers?

Good luck.

turnforthenurse, MSN, NP · Sep 10, 2012

I was the same way. Even when I started working and had to report off, I got nervous!! But not anymore, and it doesn't even have to be someone I know. It gets easier with time, trust me.

Units typically have a Kardex where most of your information comes from. It may also help to talk to your clinical instructor about what they expect in report.

SwansonRN · Sep 10, 2012

Where I work we give very detailed reports so take this with a grain of salt!

Start with the basics, pt name, age, sex, allergies, code status, and if they're on isolation. Then I talk about past medical history, their chief complaint, and a summary of their stay in the hospital so far. I then break it down by systems. That's always been the easiest way for me to organize my thoughts: Neuro, CV (I lump in labs with this section), Respiratory, GI, GU, Skin, Psychosocial.

Basically, if you're giving hand off report to a nurse just think about what the miminum you would want to know before taking care of the patient. What is their IV access? How do they take their meds? Are they a fall risk?

Giving good report is something that comes with experience so don't get down on yourself if it takes you a few tries to get it down :)

studentrnchristine · Sep 11, 2012

SBAR

Situation, Background, Assessment and Reccomendation

RNJill · Sep 11, 2012

I always do:

Name, age

Why they're here/history

Vitals/pain/accuchecks/isolation/any abnormal labs

Systems

Discharge plans

Anything random/extra

Seriously, this keeps me really organized and I don't forget anything particularly important very often

RockinChick66 · Sep 11, 2012

Name & age

Diagnosis at hospital admission

Name of Doctor or service

Hx: Any pertinent history like HTN, DM, CAD, etc

Allergies

Diet: are they NPO for procedure

Activity level: Are they "walky talkies" do they walk steady are they confused and need a bed alarm?

Or are they bedbound and need turning q2...if so, any decubs present?

IV fluids, IV site

Care plan

Report anything abnormal such as vitals, ie, elevated temp, etc.

ANY Pending procedures, MRIs, CTs, IR procedures, or lab collections,

vanc troughs due, etc.

Get ready for assessments, checks AM labs and pass medications.

Continue checking for new orders throughout the day and

SwimNurseRun · Sep 11, 2012

Dont feel like you are the first person to ever feel this way about report! It will definitely get better with time. If you have a set line to "break the ice" with every report you start, it gets your nerves settled. "mr. _____ is a ____ year old patient that came in on ____ with complaints of ______." then go on to history, diagnosis, labs, test results, etc. Head to toe assessment. (each floor is usually specific in how detailed you get with this.) And finish off with the plan for the patient. Tests tomorrow? Going home? What is next?

Aeterna, BSN, RN · Sep 11, 2012

Everyone has their own way of giving report so there is no set structure. For us, we have the option of writing out report or giving a verbal report. Writing it out is probably the better way because you can better organize yourself. We trialed a number of different report sheets, but ultimately just print out a second copy or our assignment sheets, which act as mini-kardexes - they list who the patient is, their age, sex, diagnosis, relevant medical history, most responsible physician, code status, isolation status, activity level, and any equipment they might have (i.e. IVs, Foleys, oxygen). Then, we write anything else not covered by those things in the extra space provided.

If I don't know the patient at all, things I like to get report on about them are:

- LOC/orientation - Are they confused? Oriented x3? Agitated? Behavioural?

- How independent/dependent they are for their ADLs/ambulation and how they are with toileting (or if they're incontinent)

- Anything abnormal that needs to be monitored - for example, abnormal labs, vitals, constipation/diarrhea, etc.

- Plan of care - Are they going home soon? If so, what are their discharge needs (i.e. if they are a new diabetic, do they need insulin education?)? Are they just waiting for a nursing home? Are we transferring them to another hospital? What are the goals?

Anything else, I can usually find in their Kardexes, which I always read through first before I look at report and start my shift.

As for being shy, it gets better with time and practice. Trust me, I'm a quiet person myself and was ultra-shy as a kid. I was fortunate that I had plenty of practice with piano recitals/competitions to help me gain a semblance of comfort doing things in front of a crowd, and then I did even more presentations at school and even more in nursing school. Now, I'd like to say I'm pretty good at getting up and speaking to people. I still get nervous and have to speak slowly so I don't trip up over my own words, but it takes constantly pushing yourself out of your comfort zone to get over the shyness. Just don't give up and keep trying!