How do you report-off?

[Beffers81]

So....I'm a recently new RN (January). I'm working in my first hospital but I'm having a hard time with reporting off to the oncoming nurse. I was told in nursing school to "paint" a picture of the patient; and so that's what I try to do. But I always feel on my way that I should have said this or left that out, etc......

So my question is......how do you do report? What do you include?

[loriangel14, RN]

Admitting dx, vitals if significant , how they move, new orders, any PRNs given, any concerns.

[Bob Loblaw]

We have switched to everyone must use SBAR format and have forms we must fill out- followed by "do you have any questions I can answer?"

[MPKH, BSN, RN]

I do name, code status, diagnosis, vitals frequency, if their blood sugar needs to be checked, if they're on modified diet, mobility, continent or not, any dressings/wounds and concerns from my shift.

If the nurse I'm reporting to knows the patient, then it's straight to concerns.

[BeckyESRN]

I like a decent background on the patient's admission: was in ICU, intubated for 6 days, had sx, post-op day 3, came from psych, ect. I do NOT want all of the CXRs ever performed or every normal test done. Give me a lab value only if it impacts my care(INR, K+ on pt with a bumex gtt) I always hated being surprised by a psych hold, ICU stay, surgery, ect by the rounding physician or floor supervisor right after getting report. Psychosocial issue and family issues are important too. As are tricks to get the patient to cooperate!

Ask! Next time you give report to a nurse you trust, ask if you give a good report! The day I felt like a real nurse was the day I asked one of of my senior nurses if my reports were any good and she said "I love getting report from you. You always give me everything I need"

[PapaBearRN, BSN]

Name, age, code status, allergies, MDs on the case, Hx, how the patient came to be in the hospital, procedures, imaging results, pertinent labs. Then a brief head to toe including: neuro (NIHSS?), respiratory (room air?), cardiac (NSR on the monitor?), diet (Tube fed?), GI/GU, skin (pressure ulcers?), IV fluids? Also, I like to let the nurse know what the plan for the patient is. Apologies for any grammar and spelling mistakes. Doing this from my phone.

[bgxyrnf, MSN, RN]

I give it the way I want it... short and sweet, covering the stuff that's *not* immediately evident in the chart (I'm going to review labs, etc myself regardless of what you tell me).

Specifically:

Why they're here (cc/dx)

What the plan is

How things have changed during my shift, if they have

Family issues that may bite me in the butt

Outstanding orders, meds, labs, etc.

No need to repeat everything that's in the chart.