Published
I'm moving over to ICU after being in medicine for 4 years. The nurses take report on regular loose leaf paper. I was wondering if anyone knew of a report sheet format I could use to be more oganized. Thanks Colleen
SBAR. Look it up-. It's new national patient safety issue. From the National Institutes of Health. SHow this to your leadership. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm
Unfortunately I can't just attach my report sheet to this post. I do have one that works very well for me in the icu. I've been using it for about 1 year now. Basically it covers the following:
pt id info/admit date
mds and consults
dx
recent history
remote history
drips
a list of almost all commonly done labs with lines to fill in for several days
system by system sections with a few prompts thrown in to make sure I hit everything in each system including incisions/ulcers/activity and whether they were bathed or not.
area for vent settings and ABGs for a few days
ett placement/size
area for swan readings: co, ci,...
area for radiology, cultures and other test results
and a handy check list section covering things like:
iv bags/tubing changed
labs drawn and sent
daily wt
wean eval
etc
I use my sheet over several days and keep adding to it. I try to write in pencil so I can update and change each day I have that pt. I'd be happy to e-mail a copy to anyone interested. It's in a wps format.
:typing
SBAR. Look it up-. It's new national patient safety issue. From the National Institutes of Health. SHow this to your leadership. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm
SBAR is for communicating with the MD, PA, or NP you are calling to discuss a change in your patient's status. My hospital uses it and it is a wonderful tool for this, but I would not use it for giving nurse to nurse report.
SBAR is for communicating with the MD, PA, or NP you are calling to discuss a change in your patient's status. My hospital uses it and it is a wonderful tool for this, but I would not use it for giving nurse to nurse report.
Exactly SBAR is only for change in status not shift or transfer report
AZRN4life
15 Posts
I do the same thing! I buy four color pens and have my system down: black for routine things, green for report, blue for new orders, and red for urgent matters and must-remember items (ex. allergies, procedures, etc). It keeps me organized at a quick glance.