Ideas for bedside shift report

Suggestion. As a former nurse manager, I had to monitor the number of "holes" in the MARs. One of the things we did to remedy this was to require the nurses to use the MAR when giving report to the next shift. You wouldn't believe how it helped with not just the MARs, but missed orders, new orders, new issues, AND the holes. Kudos to you for trying to improve your unit!:wink2:

doesnt medical records deal with that stuff? lets say if orders were missed or new orders didnt get input on the MARs. the medical record has a form that they use to audit the nurse or to remind them about orders that they need to follow up on..

Depends where you work I guess. Some places EVERYTHING falls on the shoulders of the nurse managers. Some places the Medical Records person would and rightfully should. Ultimately, it is the DON's license on the line when state survey or the pharmacy comes behind and starts citing people. Either way, it cetainly doesnt hurt to double check your stuff.

Our unit has bedside report. We are supposed to go into each room and give report at the bedside. Now, our unit is mostly semiprivate rooms, so I feel a little uncomfortable doing this in those rooms, due to privacy issues. I can see the benefits b/c the patient can help with the report. However, there are some things that the pt may not need to hear. As far as our orders, we have 3 ring binders with our MARS in it for each pt. When our unit clerks transcribe new orders, they copy the orders and put it into those binders, flagged for us to see. We then leave these orders in until they are complete or no longer needed. Plus we do our chart checks.

I start with the flowsheet(computerized now) and go through the vitals, assessments, etc. A good flowsheet tells most of the report in abbreviated form.

Then I take a quick tour through the medex, and point out the blood glucose, look for unsigned meds, and last of all,the oncoming nurse and I look through the orders section on the chart and check off orders.

If the patient has a complex wound, drainage systems or anything else easier shown than explained, we will take a trip into the patients room for a "show and tell".

I work ICU, and this system is typical for my workplace.

There is a Kardex that has maybe some success, but it is often not updated enough.

One issue I see with bedside report is "incidental findings" -- I had a pt who came in, had a bleeding ulcer clipped. Doc took an xray to confirm clip placement, and surprise, there was a tidy 4.5 cm carcinoma growing in the base of the guy's lung. I told the nurse coming on, but sure wouldn't have passed that on at the bedside until the doc told him.

Had another lady come in, bp was sky high, history of cva. During the course of bloodwork, found out her lack of taking her BP meds had finally killed off her kidneys -- bp of 212/105 over the long term will do that to ya....couldn't exactly say, "well, we got the Bp down so she'll probably be starting dialysis as soon as the doc gets the temp port placed..."

And think about it...if you were in bed "A" after an open chole, would you want to know that they person in bed "B" was in for not taking his paranoid/schizophrenia meds and had a history of violence, and he's the first one up for a single when we get one open...until then, try to keep him calm!?! Seen that one, too.

I agree with the others regarding giving report (within earshot) in the actual room. HIPPA laws are very strict. Also, God knows some people will prob take notes for later so they can call Mulligan and Mulligan. Not to mention people get very upset over what they dont understand. Let us know what you decide to do.:wink2:

Hey there! We just started using a form...

It has code status

history

place for IVs

respiratory

blood sugar

last set of VS

abnormal findings

abnormal labs

pain med-when last given and available again

teds or scds?

activity

and extra space to write other goodies

If I am giving report to the same gal that had the pt yesterday, I just update VS, IV's and if anything has changed.

We staple them to the pt profile. Seems to work pretty good ~Ivanna

Nothing would keep you from sharing other info about a patient before or after the bedside exchange.

In regard to HIPAA, it allows for communication even with the possibility of someone nearby hearing as long as reasonable measures have been taken to ensure privacy. So don't shout out a patient's condition down the hall, do move to a more private location when accessible, ask visitors to step outside during report, etc.

However, if someone happens to hear something about a roommate simply because they are there, that's NOT a HIPAA violation. If there's a particularly sensitive issue, then you might want to consider securing a private room for that patient or waiting til the other patient is away from the bed to address the sensitive issue. In general though, the inadvertent overhearing of private info during the normal course of provider communication info is NOT a HIPAA violation.

Depends where you work I guess. Some places EVERYTHING falls on the shoulders of the nurse managers. Some places the Medical Records person would and rightfully should. Ultimately, it is the DON's license on the line when state survey or the pharmacy comes behind and starts citing people. Either way, it cetainly doesnt hurt to double check your stuff.

It's nice to dream of! Where I work, it ALL falls on the FLOOR NURSES' shoulders! Even if the unit clerk AND charge nurse miss an order, the floor nurses are expected to catch it in report. If WE don't, then WE get written up for it! I got written up for a med order than was d/c'd THREE days before my shift because I didn't catch -- although we're told that we're only responsible for TWELVE hour chart checks (that being the PREVIOUS shift ONLY). BALONEY!

Also, that previous MAR suggestion, for during report, is a good one -- if practiced. We use a computer MAR (which is more accurate than the paper MAR that's placed in the chart by the night shift every AM). (Actually, it would be relatively accurate for them but, if lots of new meds are ordered, it would be completely inaccurate when the day shift (me) gives report.) Anyway... we're supposed to review the computer MAR (and show that meds/orders were entered on the computer!) with the oncoming nurse but very few people do it in practice. (Gawd forbid I ask a night nurse to open her MAR for me!)

Occasionally, the day charge or DON will come around just to "check up" on us. Most nurses have their computer screen up, so both with nod in unison, though there's little chart "checking" going on.

On the other end of the spectrum, though, there are nurses who will review orders for the last week, if not back to admit. I do that on occasion, esp. with nurses about whom I worry will leave (or have left) me hanging.

I am talking about from PACU to floor. Not so much a shift report.

We have problems trying to call the floor and getting the receiving RN.

They will be busy, (understandably so). But the OR's are calling out and we can't fill up in PACU and hold OR's. Not cost effective.

Anyone work in the Perianeshesia area and can shed some light.

thanks