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

[Oh'Ello]

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.

[annie.rn]

Med/Surg here:

We get a pretty good SBAR that covers a lot of things: admitting complaint, meds given, labs, vitals, assessment, IV site.

The majority of the ER nurses are good at giving a thorough report so I usually hear them out and then ask questions when they are done. I usually don't have too many but when I do, they are usually these:

Things I typically ask are things that aren't on the SBAR and aren't yet easily found in the EMR: Most recent set of vitals? Any meds given that aren't yet documented? If temp., was sepsis screening done? If screen positive, has protocol been started? (Lactate, BC, Fluids, Abx.?) If pneumonia, has pneumonia protocol been initiated and documented (BC x 2 and start time on abx.) ER is the only place that part of the pneumonia protocol can be documented.

QUICK radiology results (normal or abnormal. If abnormal, very quick reason why...I can look up the particulars)

Serial labs...next set due when? (So I can write on my cheat sheet to ensure they get done)

Biggie health history items (htn., DM, COPD, cardiac hx., recent surg., CA, any paralysis or hemiparesis, swallowing problems.)

Continent or incontinent? (So I can have supplies in the room ready to go. I like to check the brief on arrival. If dirty, I'll then have a few extra peeps to help change it. While changing, I can get a quick skin assessment and the VRE swab knocked out. Less aggravation for the pt., esp. if they are in pain.)

If the pt. is not A&O I'll ask if there is a family member or someone with them and can they please send that person up so that they can help me w/ the health hx..

And, of course, a heads up on any weird family dynamics or pt. personality issues.

Wow, sounds like a lot when typed out but it really does go by quickly. Rarely more than 5 mins.

[Mavrick, BSN, RN]

Most excellent thread. Kudos OP.

I am a PACU nurse and in my hospital the floor nurses have a standard report/brain sheet they fill out for themselves. I got a copy of one and now organize my report to that sheet so they can just fill in the blanks. Then I add stuff I think is important. With some of the newer nurses it's obvious they are not really thinking about the whole patient because they are so focused on filling in the blanks. Once the blanks are filled they are more open to seeing the patient as a person.

So I try to give them the information they want before I clutter up their minds with the information I want to give. My professional reports are 3-4 minutes, within earshot of the patient. There is very little in a post op report that the patient can't hear or sometimes improve upon.

[Mavrick, BSN, RN]

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.

I am reading this post with special interest beings as how I am a PACU nurse. First, let me apologize for our snarkiness. We have many problems to solve/prevent in the very short period of time we are allocated to spending with a post op patient. Our priority in the recovery of anesthesia is consciousness, airway, pain/nausea control. There are admittedly some things that get passed along that should have been dealt with and I agree 1200 is a mighty full bladder.

That being acknowledged, our PACU does not have a bathroom and some patients will not/cannot use a bedpan or urinal especially in such a public setting as a busy PACU. If they didn't get a spinal and don't feel the urge to void I don't get a bladder scan unless they have had an unusually large amount of fluids or length of surgery. It is not good practice to catheterize without a fair trial of normal channels. Change of shift transfer is at the mercy of the OR schedule and mostly out of our control. Also, after being NPO for 6-10 hours and only getting 1-2 liters of fluid, most people are a little on the dry side and won't void.

My pet peeve on this subject; we have a new ortho doc that will not put a foley in his total hip patients. He gives us the line he is trying to prevent UTIs but seriously wouldn't it be lot less of an infection potential to cath them in the OR while they're still sedated than try to cath them in PACU when they are hurting and it's very difficult to get clear access or they have already been incontinent?

[hecallsmeDuchess]

On getting reports, I like them short and sweet. Give me information that is important to the first couple of hours of care, the rest I can sort when I have a chance to open charts (I work med-surg), like IVs (pls tell me if it's overdue so I can change it, I won't judge you for giving me a 9 day old IV), dressings or drains are important to know, make sure IV bags are at least halfway full before you leave, have you got consents signed? post op prep done for that 0730 OR case? Update the whiteboards in the rooms, that'll cut report time even more. I like to start my day early, hate being bogged down by report because it messes up my flow.

[MPKH, BSN, RN]

Reports from ED: we get a SBAR sheet with them so...anything that is pertinent to the care that you want me to know right now, please write it on the SBAR. For example, if there is family dynamics, please indicate that on the sheet.

Reports from ICU: I do not need a fully detailed system by system report. I know that's how ICU does report up in ICU...but I really don't need to know all get in report. Diagnosis, code status, recent vitals, attachments if any, the reason they were in ICU and how was the issue treated (or not treated)...the rest I can figure out on my own. Again please tell me anything that's pertinent to the patient that I need to know now.

Shift report: a highlight of the patient from the previous shift, and any new development in the overall plan of care. Things like how often to take vitals and do flushes and when the patient last had BM are on the Kardex. I can read the Kardex ans I don't need you to regurgitate all that. Just the highlights.

[schnookimz]

Working in surgery....

Want to know:

A and o?

Npo since?

Rhythm?

Consented for surgery and blood?

That's about it....I can usually find the rest on my own. If they aren't alert and oriented then I'll have more questions.

[B,RN]

MICU/SICU:

- Previous Medical History

- code status/any physicians on case

- Why did they come to ER/ being admitted to ICU?

- Quick review of systems

- lines/gtts/fluids

- if sepsis: i want to know if blood cultures were done, how much fluids were given, and which antibiotics hung.

- if neuro: I want to know last NIH, and when the last neuro exam was completed with vitals

- Also, in our hospital, they are not allowed to come to unit without ICU admission orders being done by attending in ER/ intensivist approving of the transfer. So I need to look in chart to make sure these were completed before patient is allowed up to the unit.

I know it looks like a lot, but I can get all of that in a quick 5 minute report from ER. If a patient is going to ICU, please don't skimp on the report- we are busy stabilizing patient, drawing labs, getting ekgs, etc. and do not have time in first hour to look up details that could have been quickly discussed during report.

[OhioCCRN, MSN, NP]

Surgical Intensive care unit

1: why are they coming to me?

(Post op v/s medical emergency on the floor)

2: brief (pertinent) history

3: IV access ( or lack thereof)

4: what's you're ETA?

[RNJill]

I used to get report a lot from ER, and in response to the last thread, yes I could read a lot about them in the EMR and had no problem doing that. Really, I had NO problem not hearing about every single operation they'd had since 1968 and not hearing normal lab values read off to me. I guess what it boiled down to for was an honest and current update. This meant....

1) Brief reason for admit (the sheets we got often barely even said this because notes hadn't been written)

2) And honest set of vitals if things have changed drastically since the last set...e.g., if the BP has only been controlled for short periods after IV push meds

3) Outstanding meds/labs to give/do. And no, I wouldn't be snarky if some stuff hadn't been done. It is just helpful for planning.

4) Abnormals on head to toe; major/contributory medical history.

5) That they have a working IV. Not worried about every detail...just that it works and is hopefully not like a 24g...but if that's all anyone could get, not a problem.

6) Anything truly bizarre going on...patient is really confused, angry, etc.

....and really, I think if they're coming from ER that is a solid start.

[emtb2rn, BSN, RN, EMT-B]

ER here. All y'all are spot on on what you want to know regarding the pt i'm about to send you. We do a faxed sbar (except the unit which is still phoned) and i write all over the sbar.

I get that you very well may have just found out you're getting them and haven't been able to open their chart.