poor report

carluvscats · Oct 7, 2011

Bedside reporting would actually solve all of that; you can do a quick assessment with the nurse who is handing off to you = no surprises.

beckster_01, BSN, RN · Oct 7, 2011

^Good idea. I tend to only ask for a bedside report if the patient is complicated (multiple wounds/incisions with different care, trachs, feeding tube etc.) or if it is something I don't see very often. But it can be time consuming to do it with everyone...and I don't like passing off certain information at the bedside (behavior issues, family dynamics, techniques for dealing with difficult patients).

DookieMeisterRN · Oct 8, 2011

I love bedside reporting plus it's the law in my hospital. It saves a lot of time getting info off the whiteboard, looking at complicated wounds, clarifying LOC, checking/co-signing gtts, safety checks, etc.

TriciaJ, RN · Oct 8, 2011

I always hated getting long-winded reports about what a wonderful person the patient is, but no info about what postop day they are, if their pain is controlled, etc. I can't base my plan of care on how nice the patient is.

suanna · Oct 8, 2011

Does your hospital use an "electronic cardex" or are you still on paper? When we were on paper we kept a running daily blog about each patient- Not a part of the perminant record- just a report cheat sheet in behind the cardex. It had surgical proceedures, line placements, discharge planning and anything else we felt we needed to know at a glance. Only a few words for each day, but the mysterious disappearing Heimlich valve would have been caught and corrected before it ever got to shift change report. Since we are just starting electronic cardexes our data gathering is a bit more scattered, but I'm hoping the bugs will be worked out with a little effort. I agree, it's impossible to take good care of a patient when you don't get good baseline data to provide for continuity of care. If you can't trust the report of the shift before you- you are essentialy assessing like you are re-admitting every patient every shift.

LouisVRN, RN · Oct 8, 2011

We do bedside report but we have to get report on 5 pts in about 20 minutes from multiple nurses so there is no time to fully assess the equipment let alone do a skin assessment looking for a surgical incision from a surgery the pt didn't have. Its primarily a surgical floor so its accepted that when the pt is sp xyz procedure an appropriate assessment will be done during initial rounds. I understand its easy to miss some things in report but it never crossed my mind to question whether the pt underwent a surgical procedure when that was what was passed off in report.

TrafalgarRN · Oct 8, 2011

Hello and sorry about you frustration but i have some basic rules to avoid poor reports. We have an electronic health system and when assignments are done i will take at least 5 minutes to review the records of the patients i am getting. We have a max of 4 patients in the ED but most times we have 3 except on those rare bad nights. I always have a blank piece of paper and will glance chief complaints; orders given and done; orders pending; labs, medications given and vitals and jot them down. I also quickly glance at the MD's notes to see what the plan of care since i'm one who gets really irritated when the nurse has no idea what we are planning to do for the patient.

With such information I'm ready to receive report from the nurse and get extra information that i missed and it takes less than 15 minutes. In those 15 minutes i believe i have enough information. Then as a general rule we walk to the bedside together and at least the patient knows there is a change of shift plus if you left that urinal on the counter or your room looks like a tornado zone then you can clean up:)....your mama doesn't work here.That way there are less complaints and you can voice your concerns before the previous shift goes home. I learned it the hard way where i was being given subjective data but the objective was different. I don't care if the patient is cute and nice when for the last 4 hours you have done zilch..

If you are on a time constraint for report i would advise that you get to the floor at least 15 minutes early; review the charts and by report time you are up to date. And last not least bedside reports in critical/complex patients is a must..If i have an ICU patient i like being by the bedside as i get report. Hopefully this helps.

carluvscats · Oct 10, 2011

I sympathize with time constraints but I also do not understand why a skin assessment (at the place where the alleged surgery took place) would take more than a minute or so. You don't have to assess every square inch, just the "surgical" site.

mjmcca · Oct 11, 2011

I remember this time I had gotten report in a pt who was newly transferred from the ICU. HD pt. cant remember all the particulars it was a long time ago.

Nothing noteworthy was given in the report. during my shift come to fine a handprint shape hematoma dead center of the pts chest.

When I got a chance to speak to the pt and review the chart, the patient had been in a Dialysis center had a cardiac arrest was revived and sent to the hospital. Was in the ICU as a CPR "save".

DookieMeisterRN · Oct 11, 2011

So another one of my pet peeves has been surfacing more and more frequently...poor report. I do not want a full assessment of the patient for report but please for the love of all that is holy please do not give me inaccurate information! Just last night had a pt that I was told had a heimlich valce placed s/p thoracotomy. Okay so everyone on my floor hates chest tubes as we only get them once a year or so but I am okay with that. I have had several thoracotomy pts before and by the time they get to our med/surg unit are usually very stable and heimlich valves are much easier than an actual chest tube setup. So I go in optimistically to do my assessment only to find pt has no incision anywhere. I'm sure pt pretty much thought I was crazy as I examined entire anterior posterior and lateral chest walls looking for signs of a thoracotomy only to find nothing. Went back to the ER notes to find pt had heimlich valve placed percutaneously in the er - no thoracotomy. Went through the previous documentation to find 4/6 nurses documented pt s/p thoracotomy, one documented nothing regarding heimlich valve and one documented heimlich valves location as being on the wrong side. Its so frustrating idk what to do anymore

I would sincerely question if those nurses even did a proper assessment. Do you feel comfortable bringing this up to your NM and maybe the subject of accurate charting could be brought up in a staff mtg?

My hospital as a whole has a standardized report hand-off sheet with certain things we must report off at the bedside. So each unit has the same report process and expectations. We also are expected to turn in peer evals each month pertaining to report so there is accountability which is hospital wide and is included in our yearly evals. Everyone really grumbled the 1st month but now if the pt doesn't pipe up during report it's entirely possible to get out on time.