what kind of information do you report to the next shift?

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what kind of things do you give report to an oncoming nurse? do you report on patients who have issues or change in conditions or do you give detailed informaiton about the patient?

i have nurses who wants to know everything from last blood sugars to how patient's incision looks like. i thought to myself "you can look up that information on your own and you need to find that information by assessing your own patients" i'm used to giving reports of any abnormals.

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Specializes in Pediatrics (Burn ICU, CVICU).

what kind of things do you give report to an oncoming nurse? do you report on patients who have issues or change in conditions or do you give detailed informaiton about the patient?

i have nurses who wants to know everything from last blood sugars to how patient's incision looks like. i thought to myself "you can look up that information on your own and you need to find that information by assessing your own patients" i'm used to giving reports of any abnormals.

personally, i would consider this pretty important information, especially if there had been issues, such as rapidly flucuating glucose levels or s/sx of infection at the wound site. these things (most importantly the glucose) could let the nurse know how to prioritize her care, especially if caring for more than one pt.

i typically give a brief history, vs/sp02 baselines, s/p procedures, gtt rates, i & o's, vent settings/o2 requirements, type of access, any upcoming procedures for the day, diet, social issue, and a 12hr chart review with the oncoming nurse. of course, i work in a ped cvicu, so this is relevant info. i would imagine report varies with speciality.

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Well, mine is a bit different.. I work on a short term skilled/rehab floor, average stay about 2 months so there may not be many changes from day to day. If the oncoming nurse is unfamiliar with the floor/pts:

Admitting dx

Weight bearing status/how they transfer

Pills whole/crushed/whole in applesauce

Alarms

Blood sugars/abnormal labs/new orders

Antibiotics/reason

Last time medicated for pain

If the nurse was there the day before and there are no new admissions, then I give blood sugars, remind them of pts on ATB, and relay any new info since yesterday. It may go something like, "Mr. So and So's potassium was 3.0, was given 40 of K+ today and is to receive 20meq bid starting tomorrow, Mrs. Jones had 2 vicodin at 2pm, Mr. Smith continues on Cipro for UTI, temp 98.3, foley was out at 6am, he voided x3."

I have up to 22 pts to get through and 2 carts to count, so report is best kept short but sweet.

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Specializes in Peds, PICU, Home health, Dialysis.

I was able to observe the best shift report my first week of my ICU rotation. The night nurse not only went through the patients history but went over each major organ system. She went over Neuro, Cardiac, Respiratory, GI, GU, etc.

I also once witnessed a nurse on an IMC floor who said "This is Mr. Doe and I admitted him this morning with acute renal failure and he is stable", and then she walked away from the day nurse. The day nurse looked like a deer in head lights. She had to go to the chart and look up everything on the patient .

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

People . . .please realize that nursing home change-of-shift report is going to be very different from the ones given in acute care specialties. This thread was started in the LTC forum, so I assume the OP is looking for suggestions specific to nursing homes and extended care facilities.

Sorry, but it is unrealistic to be expected to report every little thing about your patients, especially if you have many of them. I have had 70 patients by myself as a night shift nurse at a nursing home.

I usually report ABT therapy, IV access, appointments that need to be made, dialysis, recent seizures, falls, skin tears, etc. The rest of the stuff can be looked up.

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Specializes in HH, LTC.

Agree commuter. I also work LTC and it depends on who I am giving report to. If they worked that floor the day before I just go through and say "Jim is ok, Jane is ok". and report anything unusual and maybe when their last pain med was. If they have been off a few days or are not familiar with the pts I will give dx, ADL status, any abx, pain, drsg changes, IV ABX. So it depends from day to day. Good luck!:loveya:

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Specializes in ICU/Critical Care.

When I worked on Progressive care, report seemed to take forever because everyone wanted the patient's life story. Now that I work in ICU report is shorter. Really, all I want to know is why the patient came in, what the surgery was, incisions, drains, lines, vent settings, drips, critical labs etc.

My report consists of:

Admission history

The surgery the patient had

Head to toe assessment going over neuro, resp, gi, gu

all the lines/tubes/drains/drips the patient has

incisions/wounds

Abnormal electrolyte results and what I gave

I try to keep it short and sweet. I don't need the patient's life story and neither do my co-workers. If I need to know what the last chest xray looked like I look it up. At my previous job, I had a patient transferred to me from a med/surg unit because of renal failure which is what he came in with plus pneumonia three months prior. The guy had been in the hospital for 3 months, sorry I wasn't delving into everything that went on because, I'm sorry I had 3 other patients to take care of. The oncoming nurse was very rude about it and asked "why didn't you look it up", I said " Why don't you look it up yourself", give her report and left. Next day when I came in, I asked her "So did you have a chance to look up his history?", she was much more humble after that.

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Specializes in ICU/Critical Care.

what kind of things do you give report to an oncoming nurse? do you report on patients who have issues or change in conditions or do you give detailed informaiton about the patient?

i have nurses who wants to know everything from last blood sugars to how patient's incision looks like. i thought to myself "you can look up that information on your own and you need to find that information by assessing your own patients" i'm used to giving reports of any abnormals.

had a nurse ask me which nare the ngt was inserted in, i said you can find out when you assess your patient. sorry, but which nare the ngt is inserted in is not high on my list of pertinent data.

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Specializes in LTC.

In addition to verbal report, we keep an "alert book" which is nothing more than a binder with a column for pt names, and a column for each shift. 3rd shift hand writes in each pt who has had changes in status, and adds the date the change occured and how long they will be on alert. For instance, a med change is on alert for 72 hrs, skin issues 24hrs, and so on. We hand write them in so only those on alert appear there, making it an easy reference. We record under what shift the event occured so everyone is aware when it happened. We also have a "FYI" page behind the current alert page. So if Mr. Smith will be LOA with his wife for lunch tomorrow, it's put on the FYI page. It certainly cuts down on post-its all over the nurses station!

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Okay, once again, look at the OP. This is a LTC questions. Review of systems on all the pts will not be possible. Heck, I'm lucky if I see every resident for more than a few minutes when I give them their meds or do a quick treatment. That is when they will get a focused assessment when needed.

For the most part, staff and residents don't change very often in a LTC. Even our agency staff become regulars.

Sooo, since I only work PRN I might want a bit more info from my report.

Main DX/ New DXs. Why are they here?

LOC

Crush or whole?

I'll ask who is a diabetic....any abnormals?

Any Lab work or appts to follow up on?

IVs or different tube feeding orders (like someone who would need to be started at an odd time)

Hopefully all that would be covered in the report, but if not....I ask. If they have a dx that would have any associated pain....I might ask..are they having pain?

I don't want to know what all the blood sugars are unless they are hi or low, I don't need to know that you did a dressing change that was ordered for your shift. Tell me stuff that is different or changed, tell me if someone has be having behavors all day or if the family is on a war path.

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Specializes in LTC.

New Orders, new admission with dx, I&O, behaviors, falls, skin tears all go on a 24 hr report that is on a clipboard on our cart which we go over with incoming nurse. Also if someone is LOA, such as md appointment, out with family, etc.

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I work LTC and always give a thorough report and list need to know info to unfamiliar nurses by doing an actual walk through room to room. I feel if you see an actual face with the information it will click in your head. If a resident has decreased condition I let them know if they are full code or dnr, house supervisor on staff, and Dr on call or Hospice care. Critical information is good to know cause it prevents delays in care. if I caled a Dr and he has not responded after many hours of paging (get a lot of this from medical director) I follow oncoming up to speed on reason for call. I hate coming on and a offgoing nurse doesn't tell me why she called the Dr or family and then I am looking dumb cause she didn't chart it in nurse notes! Also give recent lab report information or xrays if any are done, but I usually do a chart check anyway before shift starts. I write everything down on my 24-hour sheet and use it to give info. Organization is key to good communication!

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