Need Help with Report

[nursc]

I am a new grad and workin in the ICU. I have tried various ways of taking / giving report and haven't found a way that really works for me yet. It's like I am jumping all around or forgetting stuff. Also at times I feel I am giving way too much or way to little report. This is both for shift report and when transferring a pt.

Does anyone have any templates they use that they could pass on??!!

Thanks in advance!

[turnforthenurse, MSN, NP]

Being able to give a good report takes time. I was horrible at it at first and always got so nervous lol. Now it's not a big deal. When things calm down on the unit, I look into the patient's chart and read up on the admission, progress & consultation notes to get a better idea on what is going on and what the plan of care is for the patient. Usually the off-going nurse will tell you but sometimes things get missed.

* Patient name, age, why they are here, patient of _____ (doctor's name)

* Pertinent PMH.

* Allergies

* Code status

* IV (where it is, what gauge it is and how long it has been there for) + IV fluids & rate if applicable

* If the patient is on O2, note type and how many L/min they are receiving.

* Cardiac rhythm

* Any procedures that the patient went for with results if available (sometimes they aren't always available at that time) + any upcoming procedures (are they going for an echo, MRI, having a heart cath, or having surgery? Make sure to report that consent forms have been signed!)

* If the patient is diabetic, I tell them what their last blood sugar was and how many units of insulin were given.

* Lab values...important to note (on my floor) are electrolytes. Did they need a replacement? How much? If there were any abnormal values that were reported to the physician, tell the on-coming nurse that and tell them what the doctor wants. 99% of the time I will call the doctor about a low hemoglobin or something and they will tell me to have the day shift nurse speak to the day doc about it. Day shift nurses don't like it, but hey, at least you tried to fix the problem. And remember to DOCUMENT anytime you call the doctor - for example, "spoke to Dr. X about hemoglobin of 8; no further orders received" etc.

* Any pertinent assessment data. If the patient has had crackles all shift, tell the on-coming nurse that. If the patient had a heart cath, report your findings - any hematoma? is the dressing okay? are pulses +2 bilaterally? If the patient had abdominal surgery, do they have an incision? Any drains? What kind of output do those drains have (type and how much)? Etc etc etc.

* We usually have a computer with us when we are giving report that way we can look at the 12/24-hour I&O, lab values, most recent vitals, etc. When I give report for transfers, I always note the most recent vital signs.

* Because you work in ICU, I would note the vent settings and cm marking at the lip of the ETT tube.