Report: Where do you work and what do you want to know

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So theres a pretty lively discussion going on here about "why don't you just read the chart" in regards to finding out the info that one wants from report.

I've always understood report to be the engagement between caregivers and patients in order to sail smoothly along a continuum of care.

A few things from the other thread jumped out at me. First, that someone giving report would "guess" what the other person wants to know. Maybe here we can give each other some insight to take the guessing out of the game, split the difference and meet half way.

So tell us... where you work (what kind of unit.. what kind of patients you have) and what things you expect to hear in report. Example:

I work in hematology/oncology: mostly heme malignancies and blood disorders. When I get a patient from the ED, I want to/must know (in addition to the normal assessment stuff):

Are they febrile? If yes, what did you do about it? Antipyretic? Icepacks? nothing?

Were they cultured down there? If so where? Peripherally? from a line? What time?

What were there critical heme and electrolyte labs and what did you do about them? Give blood? give electrolyte replacements? did nothing?

Are they actively receiving treatment for their disease?

I don't care if you know what it is... but did they get chemo/radiation/biomods this morning... yesterday..?

Did an oncologist direct their care in the ED/ICU/Wherev?

If not...who did?

I know this won't be a super comprehensive list but maybe some of our opinions can help others who struggle to know what is relevant to other units and what is not.

jadelpn, LPN, EMT-B

51 Articles; 4,800 Posts

Why were they admitted? What is the diagnosis? How is it being treated? Vitals? Any PMH that is relevant? Are they A&O? Do they move and how? What is the plan? Any weirdness I need to know about?

TheCommuter, BSN, RN

226 Articles; 27,608 Posts

Specializes in Case mgmt., rehab, (CRRN), LTC & psych. Has 17 years experience.

I work in acute rehab. All I want to know is if they have any wounds/incisions, IV access, supplemental oxygen, or NPO status. I also like to know about dysfunctional family dynamics so I can be prepared to deal with the nutcase spouse when she visits.

I don't care to know who their doctor is; I can find that info on the chart. I can find their admitting diagnosis, medical history, last set of vitals, diet, height, weight, recent lab values, and other information on the chart.

All I want in report is an SBAR format. Keep it simple, factual and in order.

If I'm getting a patient from ED, I want to know is:

Why they are being admitted to ICU? Preliminary diagnosis?

RELEVANT recent history.

A basic assessment. GCS, vitals, IV access, mobility, interventions and diagnostics that have been performed and NOK is enough.

I prefer a quick but informative report when I'm getting a transfer because I want more time to set up my room.

Specializes in pediatric neurology and neurosurgery. Has 11 years experience.

Good idea for a thread. :yes:

I want to know why they're here, a pertinent PMH (i.e. I don't care about their T&A in 2012, but I do care about that VP shunt), what labs and diagnostics were done thus far, IV access and what's infusing, neuro status (current and baseline), did the kid get a rescue or a loading dose of something, if they have a competent adult with them or if family seems slow, etc. I don't need to hear recent VS, unless they are abnormal.

And in response to the OP in the other thread, who wants us to "just read the chart", here's the thing: Believe me when I say that I would love to look up the kid in the chart, and know all about them. But let me explain why this is generally not possible. I am NOT sitting at a desk. I am taking care of patients. When you call to give me report, I am either in one room bagging a kid, in another room adjusting a Becker drain (look it up if you don't know), in the bathroom for maybe the first time that day, taking someone a Sprite, on the phone with neurosurgery asking for a stat CT, etc.

When I worked nights and sometimes had time to look up a patient before getting report from the ED, I actually preferred to do so. But that brings up the other reason why I need a verbal report from you: there is generally not much info charted yet, if anything.

So for the sake of the patients, please don't assume anything (you know what they say about assuming). Just be a good sport, play nice, and give a nice, pertinent SBAR. And thank you for all you do. We're all on the same team. :yes:

RNperdiem, RN

4,573 Posts

Has 14 years experience.

SICU here. Some of my specifics I like beyond the standard vital signs, IV access, history:

If the trauma patient is coming from the ED, I like to know who they are (if we know, trauma has their share of unidentified patients), what happened, what their injuries are, what scans were done and their level of consciousness. If police is involved and there is an assailant at large, mention that.

Karou

700 Posts

Specializes in Med-Surg. Has 1 years experience.

I work on a med/surg unit.

From the ED I first want to know their complaint (what made the pt come to the hospital) and their admitting diagnosis. Did they come from home, NH, or wherever. Mental status. Activity level. What has been done to treat them and what's the plan. Any unusual lab or test results. IV access. Recent vitals.

I try to look up the chart in advance by rarely have time. Last night it was 20 minutes from the time I was notified I was getting the patient until they arrived to the floor. Thank god I got a great report :)

From my coworkers it's pretty much the same except I like to know more of the social/family details so I have a heads up. Any consulting physicians, dates of surgery and surgeon, wound care orders, ect... I really rarely ask questions because I can work with whatever I get.

Specializes in orthopedic; Informatics, diabetes. Has 11 years experience.

One of my pet peeves when I get report from PACU relates to voiding. In the process of trying to avoid CAUTIs, some of our pts are not catheterized. They also haven't voided in 8-12 hours by the time I get report. I ask if they have been bladder scanned and most times the reporting nurse gets all snarky, like it is non big deal. Mind you, this usually right around shift change too. We have had people with 1200-1500 mL in their bladders. To me that is unacceptable. I don't care what gauge IV or how much fentanyl they had pre-op.

I do look in the chart while getting report, before if I get the time, so especially if it is a routine joint issue, I really just need the exceptions not every detail.

kiszi, RN

1 Article; 604 Posts

Has 9 years experience.

I work in a small ICU and can work with whatever I get in report. For patients from the ED, I prefer:

Admitting dx or primary complaint, and reason for ICU admit vs. floor if known

Relevant history. Please don't read me their hx of appy 5 years ago, hysterectomy, etc

What fluids or blood products have been given, since these aren't always charted accurately

Drips running

Recent critical labs or abnormal VS. I don't expect fine details on their heart rhythm, but it's helpful to know if they've been throwing PVCs for a while or flipping between rhythms

Unless the hospitalist saw the pt in the ED prior to admit to floor (rare), the patient will have few orders. So they come to us NPO by default. We do bedside report so I can easily find IV sites and foleys.

What I don't want:

To know VS or labs that are normal.

To be read every medication the patient has gotten.

To hear speculation on what this or that lab value may mean for the patient, or what you feel should be done next.

I can see how much O2 they are on, and will probably change it anyway

I personally prefer short and sweet. I piece together my picture of the patient through various sources, report being the least of them.

Specializes in Registered Nurse.

I am currently preparing to go back into Med-Surg as my FT, primary job.

Report from ER or OR/PACU/RECOVERY- I want to know reason for admission or what the surgery was, dressings/wounds, other additional diagnoses, initial treatment given, any problems, any tests pending, any treatment pending such as blood products, pain levels, any unusual dynamics. There probably are a couple I am forgetting, but that is basically it.

loriangel14, RN

6,927 Posts

Specializes in Acute Care, Rehab, Palliative.

Complex Continuing Care. Have they eaten, pooped, peed, and any PRNs given. Any family issues? Do they need something for sleep?

Specializes in Palliative, Onc, Med-Surg, Home Hospice. Has 6 years experience.

I work Onc/Palliative. Here is a list of what I want to know:

Why patient was admitted/transferred and if from a nursing home, from where.

Pertinent history: I could care less who did the patients total knee 10 years ago when patient is admitted with end stage CHF

Any potential procedures.

Wounds.

IV site and fluids: particularly if they are getting mag, chemo or potassium

Abnormal labs

A&O, ambulation, level of care (Self.total, partial)

Any changes or issues I need to look out for.

Pain meds; Especially for my sickle cellers and palliative patients.

And how they take their meds if they are older/disoriented, etc.

I give/get report from one nurse who will tell stuff like: who did their surgery 25 years ago. Or normal labs. She will ask stuff like: when did they have this hysterectomy (Pt admitted for pneumonia and is now a palliative patient). I just want a simple run down.