Report time

Daytonite, BSN, RN · Apr 16, 2007

part of our function as rns is management of the patient's care. that includes knowing about all the orders that the doctor wants carried out. if a cat scan, mri, eeg or a consult doesn't get done guess who the doctor is going to go to and ream a new orifice in first? if you happen to be the rn on duty it will be you! and, i guarantee after one of these doctors reams you a new one, you will never forget to check up on the tests and consults for his patients ever again. that aside, remember back in nursing school when you did care plans and had to go through all that rigmarole about the pathophysiology and medical treatment likely to be instituted for the disease process going on? well, you, as an rn, and some of your rn colleagues want to know the results of some of those medical treatments and tests for the ongoing assessment of the patient.

a lot of these things are a matter of organizing yourself. i am posting a link to the report sheet i used. i made room on it for things like tests. as i signed off doctor's orders, i would add any tests or changes in diet that had been ordered to this sheet i was using for that day, so i had that information. i also followed up with the patient to find out if someone from lab had come and drawn their blood, if they had been taken down to x-ray or if a doctor had been in to see them--just in case i missed it. it only takes a few minutes to poke your head into the patient's room and ask these things. you'll get the hang of this. it takes time and experience. at least your peers are only asking you these questions. add some pms, a nasty attitude, someone who has had a real crappy day and is looking to kill something and they could be asking you these questions while rolling their eyes at the ceiling and looking at you like they're ready to draw blood with their claws. :lol2:

[attach]5032[/attach] my report sheet

shotnbum · Apr 16, 2007

Suggestion: cover each patient's info in report in a head-to-toe fashion, or by systems....I know there are stickys on this site with examples of report sheets. This will help you in organizing your info during your shift (update labs, orders, etc) and of course help you during report. Consults and labwork, radiology reports ARE very important....so, use a report sheet for each patient to make notes on during your shift as you check these results. I know it is overwhelming sometimes....take just a few minutes before shift change and report to pull your patients orders and ensure you have noted everything, looked at all the lab (was in NL?,abl?), etc. Make any additional notes on your patient report sheets.

Also, I have noticed some nurses interrupt, ask questions before you can get to that info. in report.... A nice way to handle this and keep on track is to say," would you like to cont asking questions and I will just answer them or should I cont with report?" (do this in a nice way....but be certain YOU are organized and cover all needed info too!)

shotnbum · Apr 16, 2007

you see!! Daytonite posted the attachment of her report sheet....:)

My thoughts exactly Daytonite!

all4schwa · Apr 16, 2007

The next thing I want to know (whether I find out from the off going, or for myself), is what did that MRI or CT say? I need to know before I assess the pt. I do neuro, so I'm always looking for those reports, and if they're not done and due, its "am I going to have to go with them?"

ETA: I dont have six pts either, 4-5.

jennyfyre · Apr 16, 2007

Do you have a unit coordinator on your unit that helps you track this? I am a HUC on a small peds/gyn unit (18 beds). It is part of my job to keep track of the consults and tests and make sure that if something isn't done, I know why and when it is expected to be done. The MDs and RNs depend on me knowing what the status is of all the things going on with a particular patient. Most of the time they don't even ask each other in report, they ask me! :) When I process orders for labs, ua/uc, stool, radiology, PT, etc. I first find out the particulars, preps and whatnot. Then I get an estimated time of occurence.. then I inform the nurse and have all the info for them to follow thru with. I also follow thru by checking that labs are actually pending in the computer, etc. It's not uncommon for me to go ask if lab has been in with a patient. If a consult hasn't been seen for a patient by about 1300, I send an epage to the expected MD to remind them. IT certainly seems to take alot of the stress of the nurses I work with when I am there and they know I'm on the ball with their patient's needs. It might be that your HUC could help you by giving you that information so you don't have to dig for it.

Cattitude · Apr 17, 2007

I am a new nurse and I have problem with other nurses in the report time. I have 6 patients. At the report time the other nurses ask me : did the pt had Ct scan, MRI, EEG? did he had psych consult, neuro consult, and so many other consults? It is hard for me keep track of all consults, especially because I have 6 patients and these info haven't told to me in the report by the last nurse. I have hard time to say I don't know and I feel so embaresed. . Please tell me what I have to do. I can't honestly keep track of all consult and Ct scan, MRI, and EEG. And I don't know what is the benefit of knowing all these info for them because they can't do anything with the result.
Please advise.Thanks

You're getting some good advice so far. I think it also depends on hospital policy also. When I worked bedside, it was not the RN's responsibility to make sure that consults were done. Dr's did that with each other.

But I do agree that you can just ask the pt. if the consulting Dr. was in.

As far as CT scan, MRI etc. Yes it's important to know if these got done and also a basic result. For instance, if your pt. is in for a R/O stroke, you'd want to know if the MRI was negative right?

Deep breaths, it takes time to feel comfortable in report..

ranchwife · Apr 17, 2007

Daytonite!!! LOVE your report page...quick, easy and TO THE POINT!!! One of my biggest pet-peeves is when you get into report and "someone" wants all the details of the patients...most of which could easily be found on the chart or kardex!!! Getting or giving report on 3 or 4 patients should NOT take half an hour!!!!

KulRN · Apr 17, 2007

I have 8 patients and I have to give report at the end of my shift on all these 8 patients. I always make sure that I give them labs that are ouside of the noraml range and if MD is aware and if there's any orders as well as any previous tests that is in relevant to their diagnoses. These are very important piece of information that we need to pass on to the next nurse. I alos noticed that some nurses just copy off what the previous nurse had reported to them....Some nurses do not bother (or maybe have no time???) to open the main chart to look for any new orders....When I start my shift I like to open my patients charts and read on their H&P, ER notes, and previous orders so that I have better understanding of what has been done and what needs to be done. I try to be thorough with my end-of-shift report and of course there's always something that we tend to forget....Report doesn't have to be long, just concentrate on the important details.

JennieO · Apr 17, 2007

Let's face it, with some nurses it is like the Grand Inquisition and they can locate the information themselves but do not want to. A cure to this is to give a very long, very detailed report with all the minutiae included. They will tune you out and they will certainly not ask questions they can find the answer to themselves. The last thing they want is you to continue to drone on and on and on. Try it. They won't be able to get away from you while givieng report.

anne74 · Apr 17, 2007

Part of it is you are a new nurse. As a new nurse, you mind is scattered into 80 directions, because everything is new to and you're trying to wrap your brain all of them. Eventually, you'll be able to save brain space by zeroing in on the important stuff, and weeding out the less important.

I used to think - how do these nurses memorize all this stuff? I used to try and write down/remember all the labs, until I figured out, which lab was most pertinent with which pts - example: liver pts, they want to know plts, albumin, lfts, etc.; heart pts, K+ !; kidneys - K+, creat., etc. With experience, you'll be able to anticipate the important things, and be ready with them. Right now you're probably trying to memorize everything - even less important stuff, and your brain feels overloaded.

Another trick - ask the doctors about the results of tests, because they won't volunteer them to you. They're too busy and preoccupied. Many times I know pts were having tests, but I would never know their meaning unless I chased down a doc - or grabbed him/her as their running down the hall - and asked "So what did you see on Mrs. Johnson's CXR?" They've always been glad to tell me, but only if I was proactive and asked. That always blew my mind - why wouldn't they automatically tell the nurses the results, especially if they provoked a change in care? But they're busy, and they don't. So you have to be aggressive, and be a detective yourself.

potato · Apr 17, 2007

ream a new orifice in first

thanks for the attachment that is a great sheet!!