Published Jul 7, 2008
silentRN
559 Posts
I'm still a little week at giving report to the on comming nurse for the next shift. Does anyone have any pointers or some sort of format they follow? It would be helpful for me.
-David H.
missrisa77
64 Posts
For report, I just follow my personal sheet. In the ICU, it's long and detailed, but this is how it usually goes...
Patient name, birthday
code status
allergies
attending docs
current hx (events during hospitalization)
past medical hx
neuro status
CV status
pulm status
GI/GU status
Lines in
skin status
family contacts
Any other thing pertinent to your shift (outputs, restraints, etc). This usually covers it all. Hope this helps!
Thank you for answering my post. I appreciate it.
dianah, ASN
8 Articles; 4,503 Posts
If you do a site search using the words "brain sheet" or "report sheet" you may find a lot more examples to use or to use towards making up your own, what works for you.
Good luck! :)
boomerfriend
369 Posts
On our unit we use an SBAR form. It seems to unify what is to be covered in report. Someone told me a while ago that you are "telling the story" about the patient. Think of it as telling your friend about what happened today. However, the report needs to be organized in a logical manner (i.e. neuro, respiratory, cardiac, GI/GU, family, etc.) You'll get better at it the more you do it. Also, you'll notice when someone gives you a good report (take pointers from them) and a bad report (note what they did and DON'T repeat it).