Nursing shift report--what's your procedure?

[ktliz]

We are moving toward a paperless report in our unit, using the computer to look up information rather than referring to a written Kardex. Previously, the off-going nurse would make a copy of the patient's Kardex for the oncoming nurse to take report on. The Kardex covers a full SBAR report--code status, allergies, history, full assessment, etc. The problem is, often the information wasn't updated.

The staff is VERY resistant, since they are used to having that instant reference folded up in their pocket when needed. Now, if the oncoming nurse wants a complete reference, he/she needs to write it all down during report.

I'm interested in hearing if anyone else is doing electronic or "paperless" report, or if you use a Kardex or some other written reference.

[Nalon1 RN/EMT-P, BSN, RN]

we waste more paper now being "paperless" than before.

We print out "active interventions" for each patient at the beginning of each shift. This has all the past Hx, allergies, medictions due, diet and such on it, basically everything but the assessment, it is usually 4-6 pages.This is a reference sheet in case the computers ever go down. I (and most other nurses) write down the report from the other nurse on that, but a few have their own sheet that they made up.

[benmca13]

We do paperless. Honestly, we rarely look at the computers. Most of our report is just done at the bedside or at the nurses desk - but I feel as if we give detailed enough report that we don't need to look at the computer. Works fine for us, I'm not sure why other hospitals spend so much time looking at computers. You should know form report what meds their on, code status, etc.

[JeanOfAllTraits]

Different nurses have different sheets. Most use one basically blank sheet. I fold mine in half and use one side for each patient. Top half had past medical history amd current hospital course. Sometimes that current is everything that has happened, sometimes its the original reason for coming to the ICU and where they're at now. Bottom of the half sheet is for the current assessment. I like a system report and most of our nurses do too. I write sections for cardiac, respirator, neuro, gi, gu, skin, IV and "needs". I sometimes write allergies, usually code status.

At the end of it all, the paper is a brain but the computer is the final back up (as long as my brain doesn't say something in the computer is wrong. ) what I don't write down is always on the computer.

[emb92250]

Personally, benmca13, I have a hard time remembering everyone's meds and PRNs and drip rates after just being told once. I write it down. And if I don't remember to look at my paper, I forget again!

I don't like, as a travel nurse, being told how I must take report. Each institution is different, and learning how to do report "their way" every three months is too much for anyone. So, I have a system that works for me. And I write down the details that I know I need to know in order to give the best care possible and to keep the patient safe.

Now, if they want me to do my note taking at the bedside vs. the nurse's station, that's fine. But actual report that I write down is my own strategy.