Problems with shift to shift report

If you will email me, I will send you a report sheet I made up. The other RNs on my unit like it so much, they asked me to please leave it with them so they can use it in rounds with the doctor. I work in Surgical ICU. So you can tweek it to your specifications.

my email is [email protected]

If you will email me, I will send you a report sheet I made up. The other RNs on my unit like it so much, they asked me to please leave it with them so they can use it in rounds with the doctor. I work in Surgical ICU. So you can tweek it to your specifications.

my email is [email protected]

HCox1975: I am a new grad in msicu & wondering if I could email you as well & get your report sheet..I would greatly appreciate it! Because like the OP I am having trouble remembering what is important to get across etc...So if I could email you as well that would be great! Thanks~

Sure you can email me. No problem, glad to help.

Hcox... haha sorry I see a trend here as well! Can I see your report sheet? I am emailing you now.. thanks a TON!

-Miniash

I would like to see your report sheet as well. I will email you soon! Thanks.

Does your facility use SBAR? It can help with a general summary. Also, try to just think in a logical order--from head to toe when giving report. Here is a synopsis of SBAR off the internet. Maybe it will help :)

SBAR was developed by Kaiser Permanente of Colorado, and has been increasingly adopted by hospitals through the United States. SBAR is used to report to a healthcare provider a situation that requires immediate action, to define the elements of a hand off of a patient from one caregiver to another, such as during transfers from one unit to another or during shift report, and in quality improvement reports. Liability issues may surround the communication that occurred in any clinical situation, but particularly when unexpected changes in a patient’s condition occur. It is often difficult to determine what the healthcare prescriber (physician, physician assistant, nurse practitioner) was told. An inexperienced or fatigued nurse may omit specific important information. One of the goals of SBAR is to provide a structure for such communication. The elements of SBAR are explained below and applied to contacting a prescriber.

Situation: When calling a healthcare provider to report a change in the patient’s condition, the nurse identifies his or her name and unit, the name and room number of the patient, and the problem. The nurse describes what is happening at the present time that has warranted the SBAR communication.

Situation: “Dr. Little, this is Maria Sanchez of 3 North. I am calling you to notify you that your patient, Liam Kelly, in Room 319-2, fell on the floor today while being transferred out of bed.”

Background: The nurse includes relevant background information specific to the situation. For example, this could include the patient’s diagnosis, his mental status, current vital signs, complaints, pain level, and physical assessment findings.

Background: “As you know, Mr. Kelly had a discectomy and bone fusion on January 17. His legs have been weak since surgery. He fell when our aide was helping him get up with a walker. His current vital signs are 145/90, pulse of 88 and respirations of 20. He is able to move all of his extremities, although he is complaining of pain in his incisional site of 7 on a scale from 1-10.”

Assessment: This step of the communication provides the nurse with the opportunity to offer an analysis of the problem. If the situation is unclear, the nurse tries to isolate the problem to the body system that might be involved and describes the seriousness of the problem. This may be challenging for some nurses because many have been conditioned to hold back the results of their critical thinking skills. Some facilities use the assessment step to convey more extensive data about the patient, such as changes from prior assessments.

Assessment: “I see no changes in his neurological status since he fell; neither of his legs is shortened and externally rotated. He is quite anxious now and also worried something his neck has been injured.”

Recommendation: The nurse states what he or she thinks would help resolve the situation or what is the desired response. This might be phrased in the form of a question: “Do you think we should give him a medication, perform lab work, do an xray, perform cardiac monitoring, or transfer to another unit? Will you come to evaluate him?”

Recommendation: “I believe it would reassure Mr. Kelly if you would examine him. When can we expect you to come?”

SBAR does work. Also, going system by system works. Cover your systems. Order, labs drips and meds and tests Should just about cover it.

Most respectfully; SBAR was originally used by the military and aviation industries. It was then, later, adapted for use in healthcare by Kaiser in CO.

To digress, if you want to stay on task with your report, you can report system by system and go down head to toe.

First and foremost, I want name, age, Allergies, Code status, Physician/group, and presenting diagnosis that landed them in the Critical Care Unit.

Neuro (LOC, pain level, sedative drips and rates, restraints, parasthesias, eyeglasses, hearing aides or HOH, spanish speaking only, CT of head results, ECG's, Neuro diagnoses such as stroke, etc.) - Personally, I will also put notable "family dynamics" in this section such as "patient's spouse is trying to slip illicit drugs into the patient from home" - mainly because now they are driving ME mental.

Respiratory ( 02 sats, vent settings - e.g. Fi02 and rates, Peep, etc, BiPap and tolerance, etc, lung sounds, breathing treatments, CXR results, sputum cx pending, ABG's, pending CPaP trials, last extubated on X date, or was intubated on X date, last pneumovax/flu shot, coughing and production, respiratory diagnoses such as COPD, Pneumothorax, etc, Empyema, MRSA isolation for respiratory)

Cardiac (cardiac rhythm, pressors & rates cardiac drips & etc, ectopy, EKG's, Chest pain, troponins/CK-MB's, BMP's, elevated D dimers, PT/INR, PTT, Lactic Acid, CBC, CMP, Echo results, edema, pulses, IV lines, CVP readings and parameter, Art lines & etc, Large volume drips....NSaline, D5, T-P-B/P, Ted hose or SCD's, Cardiac/Hemodynamic involved diagnoses such as CHF, MI, Sepsis, and so on)

Gasterointestinal - (Insulin drip, Diabetic, Feeding tubes/NG tubes, current diet, NPO status and pending procedures that require NPO even if the doc hasn't ordered NPO - we have to help the doc y'know - Bowel sounds, last BM, rectal tubes, Abdominal X-ray results, u/s results, CT results, Ammonia level, liver enzymes, C-Diff isolation or pending cultures needing to be sent, GI related diagnoses such as small bowel obstruction, pancreatitis, lipase, amylase, etc, ascites (not truly GI, but is GI located and therefore, it helps me to remember to mention it in my report), and so on.....)

Genitourinary - (Foley catheter, output that is impressively + or - in nature or color, Renal panel, dialysis and amount of fluid taken off over x amount of hours, location and type of dialysis access, don't use Left or Right arm 2ndary to AV shunt, difficulty peeing, frequency or fall risk due to urgency, diuretic doses and such - Lasix, etc, GU related diagnoses and tests....and so on.....)

Musculoskeletal - (skin, wounds, injuries, activity level/restrictions, amputations, prosthetics, masectomies, wound vac's..... , Isolation for contact isolation of x wound site with x organism, broken bones, trauma, Muscle, bone and skin related tests and procedures/results)

(I know I've left stuff out....but you get the picture)

Each system is a "file folder" and when I get report from someone who is all over the map, I just write information down under whatever system it belongs in. When I give report, I stick to going down systems on my "road map" from head to toe.

Hope this helps

Everyone has their own method, ask around and see what works best for you. I have some nurses who, if I am not returning, ask to keep my report sheet for themselves because they love it so much. Then there's other who look at it with disgust. To each their own.

What I personally like best is getting the basics, medical hx, HPI, then a breakdown of why they're still here. I don't care if they had a dilutional anemia after admission 4 weeks ago and got 2 units of PRBC, I can read the history myself, just give me the current issues and what we're doing about them.

Example would be sepsis. Alright, they've got a fungal UTI, MRSA bacteremia and C.diff. I know they're on antibiotics, don't tell me which ones, I can read the MAR. Have they had a fever, high white count, last time cultured if still spiking fevers, did you give fluids today, etc. Hit on what's important and what the nurse can anticipate dealing with for the day.

After covering the problem list I do a run through of my systems and then finish off with a to-do list for the oncoming shift like checking labs or finishing some paperwork. Run through your systems with a brief overview. Neuro I'm happy with a quick breakdown of their GCS. Don't tell me their pupils are 3 mm and reactive, but do tell me if one is blown so I don't shine a light in their eyes and flip out. Just like charting by exception, give report by exception, if that makes sense.

That's how I roll, take what works for you and try to incorporate it into your method if it sounds good.

Have you tried a bedside report? If you are having trouble remembering what happened during the day go in the room and talk about the patient. Chances are you will remember and the patient will appreciate knowing how thorough you were with report (if they are awake). Just a thought.

Other thoughts, I go system by system. Head to toe and SBAR is always useful. Have the chart in front of you so you can go over orders, that will help to spark memory too. Your educator is right, it will get better.

I always give the highlights of what brought them in, and then start from head to toe. Neuro, respiratory, cardiac, GI, musculoskeltal etc.

I work float pool and flip flop from kiddos to adults and this has always helped me.

gl