Nurse to Nurse Communication

[LewisA2]

Many patients in ICU are here for an extended period of time. The worst thing that can happen is reporting to work finding out that you get to transfer the patient to another facility, you have never taken care of the patient until today, and they have been there 28 days! I know all of the details can be found in progress notes and charting, but it seems like there should be a faster way of communicating the history of the hospital stay. Some of our nurses will take a plain piece of paper and write the date and reason for admit, then each day following write down briefly the major events that took place that day (i.e. pt exubated today, CRRT initiated or dc'd, Levo started etc..) It is so helpful to have this "story" to take a quick glance at, especially if the hospital stay is a lengthy one. It doesnt need to be a permanent part of the medical record or a hospital wide form, just something we can have available as a courtesy to each other to make the patients hospital stay history easily accessible without having to dig through weeks of charting. Do any other units have anything like this? I am looking for ideas on how to propose that we implement this type of communication within our unit, and I would like input or examples used by other facilities. Anyone who can contribute any information I would greatly appreciate!

[umcRN, BSN, RN]

I work in a NICU...want to talk about lengthy stays?! (4...5....6...and yes..12 months plus!)

We have computer charting and our "progress note" area is almost exactly like you describe. The note will initially open to a list where every day we add the date, am/pm and then the major events of the day, admitted for...went to OR/extubated/coded/ecmo/septic work up etc etc, (if there are no changes we will write no change) and then there is an additional "note" section where we do our actual DAR note but opening the "RN Situation" which is what it is called is a really easy way to give report and cover all the important dates and basics.

[CRIMSON]

The nurses on our CVICU use a very simular process. Everyone has their own "report" form they like to use. I use one I designed for myself and keep it for as long as patient on the unit in cases I need a quick reference. Also, our flowsheet carries over an acute history of why patient here and what procedures/treatments have been performed since admission. We fill these in each night for the next day.

[pawashrn]

personally. am I being cold. I treat any pt. I receive as if they just came thorough the ER and no knows anything about them. Does it really change your nursing care to know they had dialysis 20 days ago. no, you are assisting in the care at this present time. It is up to the physician to know the previous care given in order to plan the future care.

[steacer]

One of the ICU's that I worked in had this information on the kardex, (something I'm desperately missing now) and when the patient's stay was excessively long we cut out that piece of a new kardex and taped it to the old one, giving us a page 2 of their stay. And of course the summaries can be made briefer as their stay is prolonged.... sometimes "nights" would recopy the kardex when it gets old, ratty and excessively detailed. That ICU also photocopied kardex's for the wards/stepdowns, but kept the original so we didn't lose all the information when the patient would inevitably bounce back.

[eliyel]

We jot down important details on the KARDEX. Yes, we still have those. Or sometimes, I try reading the MDs clinical abstracts saved on the computer.

[cardiac.cure03]

There is a place in our computer charting system we use (called EPIC) that has almost exactly what was described in the original post. You can easily see all of the notes, the initial H&P, the consult notes, progress notes, everything in one screen. It's awesome. I love it!