PLEASE, someone tell me what makes a "good report" for M/S nurses?

  1. I give the admitting dx and date, iv sites/fluids and date, any problems or pain mgmt issues, and that's pretty much it. Anything else can be found in the EMR! One or two RNs act like I'm the worst just bc, well I must guess they don't like my reports because I haven't sorked with them and I haven't had a problem with nurses on my shift!
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    About Nola009

    Joined: Oct '13; Posts: 941; Likes: 1,287

    12 Comments

  3. by   sugar12
    Everyone is different but I like a complete head to toe report along with anything that's pending or critical. We also tell all the doctors on the case and if there's anything the pt prefers I would like to know as well. Usually takes 5 mins not long at all.
  4. by   jayjaybsnrn
    U also gotta tell them what kind of procedures the pt had done. Read the case managers report if what is the plan for discharge, how long will the pt will stay.

    It really depends. Some nurses just wanna know if whats the plan especially ots in the shift report paper already anyway. And some others really dont like u if they just feel that they dont like u.. does that make sense? Especially if u are younger than them because they easilly get intimidated..
  5. by   sugar12
    Yeah I agree with the previous posters. Plan of care, discharge planning and tests performed and pending are important too
  6. by   ambitiousblonde
    I'd personally like to know their medical hx, pertinent surgical hx, neuro status, activity level, are they a min/max assist..Any consults needed/pending. Are there any drains, foleys, dressing changes, wound care...
    I wouldn't take it personal, but as that they want the most information given in a short report. This is not only your patient, but also theirs. You want your patient to get the safest and best care possible. Yes, I'm sure it is in the EMR but what if that nurse gets busy right after report and doesn't have time to look at the EMR before a MD calls or they need assistance to the BR, or all the sudden has an emergency.
    What you have listed doesn't tell me what the patients baseline is. Do a quick review of systems.

    Constantly be thinking in terms of the patient, no personal issues.
  7. by   DBK99
    We do bedside report on my floor, and this is what we give during report: Name, admit dx, relevant medical hx, are they A&O or confused? If they are on a heart monitor or not, how do they get up? (up ad lib, assist x 1, max assist, dependent bed rest?), if they have PT/ST/OT, how do they go to the bathroom? Bedpan, bedside commode, incontinent in their brief, catheter, ostomy, or do they walk to the bathroom? etc. Do they have a PIV, PICC, central line and where is it, what IV fluids and what rate. If they are diabetic, how often are their accu cheks and do they have SSI? Are they on O2, or RA? Do they swallow okay, or do I have to crush their pills? Any skin issues, pressure ulcers, wounds, drains, dressing changes. If they are on tube feeding, what rate is it running? What have their residuals been, any water boluses? Where they were living before they came in? Home alone, home w/ family, nursing home, and who is family contact I can call if I need anything? I work on a geriatric M/S floor and most are confused, and almost no one can get up by themselves, so knowing who their POA is or family contact who can make decisions for them is very important for us. Also, any tests/procedures/surgeries scheduled for that day. Then I will step out of the room and tell the oncoming nurse any psychosocial/family dynamics issues. We have a kardex sheet for each patient that has all of this info on, that we use pencil to erase and write in anything new or updates during the day, that we use for report, and I love it. I don't know about you, but after getting report, I don't have time to go digging for all of this info in the EMR for 6 complex patients before AM rounds and meds. I know it's a lot of information, but our bedside kardexes really do help, and it doesn't take much time as one would think
    Last edit by DBK99 on Nov 26, '14
  8. by   Nola009
    I guess I do tell a little more than what I said, like activity level and bathroom issues/nonissues, but I had no idea how to find what they are doing, where they are going at d/c in their notes ... thanks jayjay, I will try case workers report! Our e charting system is crappy, hard to navigate, but I will look for case work bc they do have a small section somewhere in there. I get crappy reports from some of these same nurses and I don't say anything xcept OK! I'm not gonna take their issues with my report badly, but it's almost like some of these are asking 1 000000000 q's they can easily find on their own the answer to on their own, or could have on day shift my patients dont get much besides labs at night
  9. by   DatMurse
    I am still a new nurse but I want to heart The "WNL Excepts". I do not care if their pedals are palpable if you say it is WNL.
    If VS are stable/WNL they can simply state that.

    If they run tachy, is that their baseline? are they tachy r/t to sepsis?

    Whats the plan. I always ask what the plan is. Where do they come from? Do you think they need any services on DC?
    If they got a thora/para how much did they take off?

    Anything odd that they do?? I have a patient who makes up stories and that is his baseline. Not confused but just does it to screw with people(srs).

    Do they need meds with applesauce? Do they request food with their meds in the morning?

    Does my patient turn into a gremlin at night? and if they do, does ativan or haldol work?
    how do they ambulate?

    If they have a GI bleed/jaundice have you seen their stool?
    Pain meds have they had a stool?

    If I am passing someone from days to nights and nothing has changed. They can give me a high five and say unchanged(I am fine with this from some nurses).
    HOWEVER, if I look at their charting and something bad happened I will be pretty upset.
  10. by   onedayitllbeme
    Dbk99 that sounds almost identical to where I work. Also geriatric medsurge. We use to. Have a sheet like that but they got rid of it. We also include code status and DVT prophylaxis.
  11. by   DBK99
    Quote from onedayitllbeme
    Dbk99 that sounds almost identical to where I work. Also geriatric medsurge. We use to. Have a sheet like that but they got rid of it. We also include code status and DVT prophylaxis.
    Dang it, two things I forgot, we do that too! Lol
  12. by   Levitas
    Most of which was already mentioned. Depending on where I am (Med/Surg, ICU), and who I'm giving report to (some like it brief, others like it like I do, thorough).

    Where they're from - Home, retirement community, nursing home, etc.

    Code/POA/Guardian status - Name and phone number in chart, if latter.

    Orientation - Baseline, changes.

    ADL's - Ambulatory, continent/incont., using a bedside commode, urinal, bathroom, self care, total care, gait.

    Review of systems - Changes, or if it's the first time with the pt., a run down of all, if feasible.

    Psych status - Affect, mood, sitter order, history, compliance.

    IV - Size, location, how old, hard/easy stick, saline locked, fluids running.

    Telemetry - Box #, rhythm, changes, etc.

    Labs - Most current abnormal, and any relevant (cardiac enzymes, UA, drug screen, etc.).

    Radiology - Results, upcoming.

    Procedures - Upcoming, and completed.

    VTE prophylaxis - Or DVT, if you prefer.

    IV antibiotics - Especially Vanc./Gentamycin.

    History - If relevant, what interventions are in place, i.e. DM - Accucheck, how often, Conventional/Intensive SSI.

    PRN medications - Last time given on all.

    Patient requests/complaints - I like to know what my patient wants/needs, if possible, even before I hit their room.


    Oh, I'm likely missing something.
  13. by   heron
    My primary experience doing inpatient is in acute medicine, long term and long term acute care. Here's what works for me: Name, age, dx and significant comorbs, brief (one or two sentences) history of current admission, where they're at in the treatment plan, pending studies/labs and current abnormals, lines in, lines out, wounds, nourishment/elimination issues, brief review of any affected systems, significant changes on your shift and any follow-up she needs to do. If there are thorny family or social issues that the oncoming nurse might have to fend off, I like to provide a little early warning, ie an intrusive family or chaotic/dysfunctional home situation.

    Not all these points are included on all pts or for all nurses - if the oncoming nurse is familiar with the pt, you can update from when she last worked. If I were an agency nurse on my first job on your unit, or a float or just back from vacation, that's the info that would help me have some idea of where my priorities should be before I start my workday.

    Since you probably don't know who your relief is until she finds you for report, it helps to be able to think on your feet. It gets even trickier if your relief is acting out - there's no control for that - you have to learn to spot it early and develop strategies for neutralizing it. I tend to give report rapidly, looking at my cheat sheet the whole time - and I talk a bit rapidly. They have a harder time interrupting and I don't have to look at eye-rolls. I've learned to ignore the teeth-sucking and sighs of frustration. At the end, I ask "any questions?" If I can answer it, I do. If I can't, I say I don't know. Period. If they start in with the "why didn't you ..." or try to suggest that I stay to get the answers or do the follow-up, I just shrug and look at them and say no. Then I punch out and go home. It's all about boundaries.

    ETA: It's been a while since I worked acute care, but I have to agree with the posters who wonder where an acute bedside nurse is going to find the time to review charts before she has to make decisions and provide care.
    Last edit by heron on Dec 2, '14 : Reason: added thought
  14. by   tokmom
    We have a template nurses have to use at bedside that they give in a specific order. It's name, diagnosis, age, pertinent history, day of stay, drains, mobility, pain, diet, etc. It ends with barrier to dc. It keeps the info consistent and interruptions minimal because people know what's coming next.

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