Reporting off to staff nurses as a student

Nurse Kyles, BSN, RN · Nov 17, 2011

Do you have an organizational sheet? I take report on my organizational sheet in orange. Then throughout the day I write all my info down on the appropriate part of the sheet in black.(So I can differentiate which info is new) When I give report I just go in order of my sheet (neuro, cardio, resp, GI/GU etc)

All of your above info is good. If you don't have access to a pre-made report sheet on your unit, I would just make one with little boxes for all the info you have listed. I would also include a spot for each system so you can write down abnormals you found in your assessment.

If you want a couple sample report sheets, I would be happy to share a few that I have acquired. Good Luck!

Somewherenear · Nov 17, 2011

Yes, I'd be so grateful for any resources you could send me... I think having a piece of paper to write all of the info down is VERY helpful. Thank you!

KatieJ91 · Nov 18, 2011

We are given a document called an SBAR for our reports. If you PM your email I will send it to you.

Nurse Kyles, BSN, RN · Nov 18, 2011

Here is my favorite report sheet. What do you think?

Report Sheet-2.doc

NCRNMDM, ASN, RN · Nov 18, 2011

You sound like you're covering everything, and you sound very thorough. I don't tell the nurses all of the information that you talked about. We work on a surgical floor that also takes ICU step-down patients, so the chief complaint, or reason for being admitted, doesn't really change. They should be able to flip the chart open and see that, or they should already know (we report to the dayshift nurses and they, in turn, report to nightshift). I include last vital signs, and I also include a basic summary of their head-to-toe assessment. We do focused assessments on our unit, so we aren't doing a full and comprehensive assessment. I don't bore them with the details, I just let them know that all systems were normal, or I carefully describe any abnormalities. If I witnessed my patient void or have a bowel movement, I will include that information in my report. I tell them that all the meds for a certain time have been given, for instance, "I've given Mr. Smith in room 111 all his 9:00 meds." Some patients on our floor are getting 16 and 20 medications at a time, and I know the nurses don't want to listen to me while I recap every one of these drugs. As for orders like NPO, etc, they heard all of this in the AM report, and there are signs on the chart and on the door to the patient's room. I feel like reiterating that would just be monotonous and annoying to the staff. If the patient is traveling off the unit for a test, I will remind the nurses and let them know that I will be going with the patient, if I only have one patient that day. As for labs, I don't mention them unless something is really obviously wrong. If the staff mentioned in report that the patient's potassium has been 5.6 for 14 hours, then I'm not going to go run to the nurses and let them know that the patient's potassium is 5.6. Our patients get so many labs that if I detailed every one of them, I would be reporting for over an hour. I try to keep things brief while still painting a sufficient clinical picture. If my patient is sicker and has more going on, then the report will be longer. If my patient is closer to discharge, or is recovering well, then my report may be ten minutes or less.

turnforthenurse, MSN, NP · Nov 21, 2011

Giving a good report takes some time to develop. I was uncomfortable as a student and uncomfortable for awhile as a nurse, too. You will also learn that each nurse is different - some want all of the details, others don't. We do bedside report at my hospital (though lately we have been getting away from that...) and we always try to have our COW with us to look at histories, medications, VS trends, labs/tests, orders, etc. This is what I typically include in report:

* patient's name, age, dx

* attending physician

* code status (very important!)

* allergies (also very important!)

* histories (I try to stick with the more pertinent ones if the patient has an extensive list, such as hx of MI, CAD, PE/DVT, COPD, DM, renal failure, etc...they can easily be looked up on the computer)

* IV: gauge, location, how old it is, and if there are any fluids infusing (so for example, "patient has a 22g to the left forearm that has been in for one day with NS @ 50" or something like that).

* any drains, such as an NG, G/J-tube, ostomy, JP/hemovac, chest tube, foley, fecal management bag...etc.

* I don't report VS unless there are abnormalities, but I keep the most recent handy just in case. Again, something that can be looked up in the computer.

* labs. typically H/H, BUN/Cr, lytes, last blood sugar if the patient is diabetic. note any critical values.

* pertinent assessment info. typically we report the abnormals...such as adventitious lung sounds, if the patient is oliguric/anuric, not A&O/confused, etc.

* diagnostic tests - if the patient went for anything on my shift and also if the patient is due to have any procedures during the next shift.

* consults, if the patient has any. If the doc came and saw the patient during the shift, I tell the on-coming nurse that and if any new orders were received, etc.

* things that need to be done...for example, I once called the doc about a Hgb of 8.1 and they simply told me, "just let the next shift know." I documented that (cover your butt!) and did just that. I also had another patient who had antibiotics due at 0400 and 0600 but because our pharmacy isn't available after hours (and this patient came at 0445) I had to call our remote pharmacy to reschedule and retime them...so I will let the next shift know this. Things like that.

That's basically it. I always ask the on-coming nurse if they have any questions for me, and that helps in case I forgot something. Again, some nurses will want ALL of the details and others won't.