Nicu end of shift report

I just started in NICU as well a few months ago, I'm still on orientation but report tends to be something I still stumble over a little. Luckily we have a pretty standard format in our unit and while I will sometimes refer to my "brain" sheet I follow to format as much as possible, we give report off the computers starting with the H&P. From there we go to "RN situation" which I guess is kind of like a kardex, it is a daily log written by that shifts nurse about the major events of the day, ie coding/intubated/pressors/weaning vents or drips/feeding etc, we go through that to give a general overview. Then we go over the Orders, the MAR, Labs and the Physical assessment by systems, after that its pretty hard to miss anything.

Hope that helps :-)

This isn't a form, but I use this to kind of keep my brain together. It's hard sometimes when people start asking questions leading to things out of order because I depend on following this to not forget anything!

Basic history, e.g. this is Susie, and she was the first of twins born at 23 4/7 for preterm labor, now 3 days old. Include basic social/family history here.

Neuro, history of IVH or other neurological compromise

Respiratory, including type of ventilatory support, lability, spells, suctioning, major events of the past 24-48 hours.

Cardiac, including BPs, pressors, pulses, CRT, color, etc.

Fluids and access. Here I include current meds, reviewing the MAR and any use of prns.

GI, including feedings, tolerance, any history of feeding intolerance, NEC, etc.

Urine and Stool output

Review recent lab results and next labs

Review current orders, highlighting changes on my shift.

Include in each of these categories any recommendations.

At the end, I try to give a very brief summary of any nearby babies, especially if there is a lot going on and the nurse may be called to help. Then I let them know if I can be reached on my cell phone for further questions and for how long....but once I got settled into this routine, I haven't had to be called! Don't worry, the longer you are around, the more comfortable you will feel!