How do you like report?

jessiern, BSN, RN · Oct 14, 2009

Listen to the reports you get from experienced nurses. After time, you will start to pick up on what's important to tell, because you will figure out what you need to know about a patient.

Keep a list of things you need to telll the oncoming nurse. It's hard to remember to tell a nurse after 12 hours that a patient needs to be NPO after MN.

Definetly let them know any changes in the patient. What treatments are being done. What tests they have in the morning.

86toronado, BSN, RN · Oct 14, 2009

An experienced nurse on my floor told me to go system by system, starting with the reason they are here, for instance report on a typical patient for us would go like this:

Patient A, here for CVA- A&O x1, moves left side 5/4, right side is 1/1. PERRLA.

Then move on to each of the other systems:

Patient A is on tele, A-fib 90-100's, BP stable. NPO pending swallow eval, 1/2 NS @ 100ml/hr going until PO intake adequate. Foley in place, urine is clear amber, no BM tonight, patient's last BM was prior to admission. Skin is intact, patient has been turned and positioned Q2h throughout the night.

Then move on to what needs to be done for that patient today:

AM labs including CBC, BMP, ESR, and fasting lipid profile have been drawn, results not up yet. Patient is scheduled for MRI, Carotid U/S, and echo today. PT and OT have also been consulted, along with ST for the swallowing eval.

Finally, end with:

Any questions

It takes a lot longer to type than to say. You should be able to get through it in 2 minutes or so. My facility also uses these handy SBAR sheets that give you cues as to what to cover, you could probably do a search of this website to find one like it if your facility doesn't provide them. Hope this helps!

CathyLew · Oct 14, 2009

heck, in my hospital, it dependend on the nurse I was reporting off to... which makes it hard to generalize! I knew nurse A wanted all lab results, and tests that were to be done that day.....Nurse B wanted VS, current wt, I&O and just outstanding stuff. Nurse C wanted to know how the patient transfered, last BM, any social work type issues, or discharge planning issues... you can't cover the whole chart in report. and I think its trial and error finding out what each nurse wants to hear.

mandykal, ADN, RN · Oct 14, 2009

when i get report i usually write it in a different color pen... so i can differentiate what i do on my shift, as well as what i'll be reporting at the end of the shift as "previous shift reports..."

start off by the patient, age, admitting dx., code status, mental and physical state and condition. iv's, (site, type of access & condition of site). tests or following tests include labs. sometimes meds if appropriate. fingerstick(s) coverage, respirtory treatments. intake and output esp if pt has any active drainage....hope that helps.

anonymurse · Oct 15, 2009

Take a look at the SBAR format of reporting and use that as a general outline of what order to put things in.

flygirl43 · Oct 15, 2009

report H1N1...even if its on another wing or floor. Not everyone is privy to your info. Protect us please....................

meandragonbrett · Oct 15, 2009

All I want in report is:

Admitting dx. s/sx, chief complaint

Why they were admitted to the ICU (sometimes it's not obvious)

Allergies

Pertinent RECENT procedures (I don't care that they had a CT and Echo done last week)

Airway and vent settings

What drips and rates

Neuro assessment

Anything outstanding that needs to be done that you didn't get to

Chart check

I like it quick, dirty, and concise

charley75 · Oct 15, 2009

We use SBAR also, I work in ER and this week going to start faxing report instead of calling floor. We are to fax our SBAR and doctors orders. How does your ER give report. We used to do it verbally over the phone, now if unit pt we have to go along with the pt after faxing report, which we have always gone with but usually called!!

law3576 · Oct 15, 2009

I work on an oncology med floor and i give report starting with the patients name, attending doctor, admission date, age. then i go to diagnosis, history, allergies, if they are on any precautions ( fall, aspiration etc..) Iv site and it if it saline locked or if they have fluids left and how much is left in the bag. then i go to diet, activity( up ad lib, bedside commode, incontinent) any procedures that they have done, assessment ( a & o x3, clear lungs, positive bowels, last BM, skin integrity, any edema, pulses, )

any antibiotics they're on, urine color, if they receive NEBS, if the patient has issues swallowing pills, and other things like that. i give a long report but i think it's helpful that way. I

flygirl43 · Oct 15, 2009

I went to work 2 months adg and the lovely nurse forgot to inform me about the H1N1 quarantine on the sister ward (physically attached, clean core is there) Thanx alot!

tokki2u · Oct 15, 2009

I've been out of bedside nursing for a long time. What is SBAR?

Thanks.