report format

[Guest219794]

while sitting next to a new grad who was a bit concerned about giving her first report to the floor. i put together this quick form as a resource.

this is not meant to be an official document, just a resource.

i am interested in any feedback.

if anybody has a pre-made document they find helpful, i would like to see it.

name

age (gender if not obvious)

pertinent medical hx

allergies to medications

pt is being admitted by dr. ________ for:___________

safety needs-fall risk, skin risk, etc

came to er at _____ (by ems if applicable) c/o:______________

describe pertinent interventions by ems, or at home. (ntg, asa, nebs, etc.)

pertinent assessment findings

while in the er, pt received:

meds

fluids

treatments

pt's response was:

other nursing interventions, ordered or not.

vitals including telemetry

pertinent lab and radiologic findings

iv gauge placement, and running gtt's

psychosocial issues: (family concerns, etc...)

for critical pt's a brief systems base report: at least mention each system, even if it is wnl, or you have not assessed it. this shows that you are aware that the system exists.

neuro

cardiac

respiratory

gi

gu

integumentary

[chare]

I think that you have a good format that will cover everything that needs to be addressed. I would only add that I would address all systems for every admission, if only to state that the findings were within normal limits.

I have included the format that I use for report when I hand off the patient to another unit.

Name, age, weight, admitted by Dr ___ to Dr ___ for ___.

History SAMPLE (adult): Signs/symptoms, allergies, medications, past medical history, last PO intake, events surrounding incident

History CIAMPEDS (pediatric): Complaint, immunizations, allergies, medications, past medical history, events surrounding incident, diet/diapers, signs/symptoms.

Assessment/interventions: Neurological, respiratory, cardiovascular, GI/GU, musculoskeletal, integumentary, psychosocial, other.

When I give report I find it easier to discuss assessment and interventions together, I describe my initial assessment, then interventions/treatments, then reassessment/response to treatment. When I leave a body system I have addressed everything pertaining to that system.

I hope you find this information helpful.

[AirforceRN, RN]

Personally I would but the "admitted by/for" info before the pert hx info.

It may be just me but I get frustrated if I have to listen to 10 diagnoses (ie "patient has a history of IDDM, Htn, GERD, MIX2, etc etc etc) before I hear the "pt is here because of" statement.

I just find it easier to work things out in my mind of i know why Mrs Smith is here in the first place.

[Guest219794]

Some good points, thanks. I made a couple tweaks.

I actually think the tradition of a detailed verbal report is a bad idea, particularly in the environment of computerized charting. It is like a big game of telephone. Verbalizing lists and details that are already documented in the system and easy to look up, adds nothing but risk. In fact, there is no real reason that most computer systems couldn't generate all the details in one report form, and the verbal part would be focused on things not included.

A lot of floor nurses seem to have a check list of things they expect to hear in a report. I find it easiest to help them check their boxes and fill their blanks- makes report actually faster than giving what I think is a good report, then answering questions. For example, where I work now, they always want to know which arm an IV is in. A- this is documented in the computer, and B- it isn't really hard to find the IV on the patient.

If everybody read the most recent H&P (when possible) on a pt before report, it would be faster and safer.