Nursing Clinical and Report

  1. When I take report, What information should I be writing down? I take report on all the patients that my team has for the shift. How can I make it simple?

    Currently, I write on a large index card in addition to my kardex. I write DX, pain meds , when last given, I&O, Diet, VS, if the pt has breathing treatments and other special considerations.

    I think I am geting enough information, but I wonder if I am writing too much. Many of my class mates only take report on their patient. Is this what I should be doing or am I on the right track?
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    About weirdRN

    Joined: Mar '05; Posts: 618; Likes: 42
    LTC Nurse
    Specialty: Long Term Care

    2 Comments

  3. by   dbsn00
    Unless your instructor wants you to do it that way just get report on your patients so you don't overwhelm yourself. If the patient is new to you get their dx., VS & current condition, recent lab info, med info (ABT, PRN, routine pain meds) & special considerations. Keep a little pocket notebook with you to write down info you collect throughout the day on your patients - helps with charting & passing info onto the next shift. Hope this helps, good luck!
  4. by   mandykal
    dbsn00

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    "BUT YOU DO NEED A WEATHERMAN TO TELL US IF IT'S GOING TO RAIN OR SNOW."

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