Report - acute/critical care

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Specializes in Acute Care.

Management wants us to utilize some type of tool or paper during bedside report to reduce amount of time in report and be more cost effective. The paper could/should include patient history,code status, history, and possibly reason for admission and/or timeline of events pertinent to admission (important labs, codes, transfers to/from units, procedures, etc).

Does any one else's facility do something like this? I'd like to take a look at any forms utiliZed if able.

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This would be called a Kardex

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During my ICU preceptorship, we used a sheet of paper that sounds very similar to what you are describing.

There would be a pt sticker on the top right corner (name, dob, attending provider, age, MRN, etc)

Next: Dx:

Hx:

code status:

then a system by system assessment...

Neuro: LOC, pupils, glascow

Respiratory: Sounds, vent setting, etc

CV: BP, pulses, HR, tele, etc

GI: bowel sounds, feeding tubes

GU: foley/urinal, etc

Skin: wounds, dressings, etc

IV: heplocked, central line, what are they receiving

OT: one touches, insulin gtt, etc

Psychosocial: where did they come from?, POA, where are they going, current needs?

consults:

Labs:

24 hr changes:

I'm sure I am missing something, but it was a really good sheet. You gave report using the sheet and you documented the shift report received on your own sheet. As things changed throughout the shift, you update your sheet and give to oncoming nurse. I really liked this for report as it covered all the body systems in a logical head to toe assessment, which alleviates unorganized report...

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Specializes in Critical Care.

Everything you're looking for should be in the chart, you shouldn't re-invent the entire chart to give report, the "timeline" would be a kardex, which are hard to find these days. We use a modified form of a kardex which is basically a calender with some other information that isn't easily accessible in the chart. For report, we built a screen that pulls all these bits of information from the EMR to a single screen.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

organization is key.....maybe a good report sheet will help....

doc.gif mtpmedsurg.doc

doc.gif 1 patient float.doc‎

doc.gif 5 pt. shift.doc‎

doc.gif finalgraduateshiftreport.doc‎

doc.gif horshiftsheet.doc‎

doc.gif report sheet.doc‎

doc.gif day sheet 2 doc.doc

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Specializes in Acute Care.

I am not referring to a report sheet.

This is a separate sheet or sticky note to pass from nurse to nurse during report, to avoid having to write down pt history and such every single time a patient is transferred to another nurse at shift change.

Sure, we could use a patient chart, but when you are giving report on 3-4 + patients, it's difficult ot carry the charts to and from the room for bedside report. Also, it would take much time during shift change to go through a chart for all this information. We are only given ~20-30 minutes for report on all the patients.

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Specializes in Emergency & Trauma/Adult ICU.

There shouldn't be a need to regurgitate the timeline of events during a patient's stay in every change of shift report. Why the patient is here -- physical assessment & pertinent labs/diagnostic results -- what happened during your shift -- what you know about the plan for the next 24 hours -- pertinent family/discharge planning issues -- and that's about it. If your charts are still paper you can just place a piece of paper in the front of the chart where procedures, testing, and major changes in the patient's status (rhythm changes, etc.) can be listed by day. Allergies & PMH can be listed at the top of the sheet and then they are there for all to see -- no need to cover this in report.

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