No Experience with Written Report Format

[UM Review RN, ASN, RN]

Our unit has recently changed to a written report format.

Everyone loves it except me. I feel like I'm a way overpaid secretary.

I spend half the shift reading the entire chart, doing the chart checks, updating the Cardex, then repeating much of that info--copied by hand (as if I didn't have enough writing to do! )--on the written report sheet.

I'm at a loss as to how to streamline this process. For those of you who use written report, do you have any suggestions before I have to claim worker's comp for carpal tunnel syndrome?

[leslie :-D]

it's nothing really formal;

some facilities have a 'report' book and you write the pt's name and anything remarkable going on with him/her.

then onto the next pt.

but what is redundant is after writing or taping report, you still have to give a verbal one to the oncoming nurse.

[Tweety, BSN, RN]

We do a written report and it's very tedious I agree. We hated it at first.

Do you really have to read the entire chart when you do your chart check? I usually quickly skim the progress notes, and the history if it's a patient I don't know. I don't update the cardex, that's the secretaries job when she takes off the orders. If the cardex isn't up to date I let that go. The written report should have what you need on it anyway.

Our written reports are outside the patients room and we'll do a walking round with a very quick verbal report. The time I spend written the written report prior to shift change makes the shift change report go very fast, because the writing is done ahead of time. Used to be people came in, looked at the cardexes and wrote report sheets to organize themselves, then took a lenghty verbal report. Shift change could be 45 minutes to an hour. Now it takes 10 minutes!

Good luck.

[harley_fan]

I used to do written report at another facility and we had a sheet organized w/ different systems/topics to be addressed. The topics included nutrition/elimination - we would write what diet they were on, any fluids going, LBM, if they had a foley in, incontinence. Other topics include safety issues, tissue perfusion (edema, VS, neurovascular checks), Respiratory (lung sounds, oxygen needs, suctioning), Anxiety issues, Activity (if they are SBA, assist of 1..2.., use of assistive devices), Plans (when they plan to be dc'd and tests/procedures scheduled). Hope this helps.

[UM Review RN, ASN, RN]

Thanks for your answers. I think I have a better idea about where I'm spending too much time now.

I don't update the cardex, that's the secretaries job when she takes off the orders. If the cardex isn't up to date I let that go.

I've been writing the pertinent X-Ray or Specials test reports here, for instance, a CT Angio result that looks suspicious. The unit secretary doesn't do this particular type of update.

In order to do this update, I have to either read the chart and type the result on the Cardex, or I have to write it all out by hand on the report sheet.

I was hoping I could get away with merely writing it on the Cardex, so I tried it, but the idea was shot down in the interest of consistency.

We have to write it all out by hand, even though the same info might be on the Cardex at this time. However, a bright spot: someone created a flow sheet, and they're hoping to start using that soon instead.

Meantime, updating the Cardex is going to go out the window, I guess.

If this works and gets everyone out on time--not just day and evening shift--I'll adjust.