Jump to content
Additional Hardware Upgrades Read more... ×
MaryCQB MaryCQB (New Member)

Shift report form

CCU   (70,558 Views 26 Comments)
1,411 Visitors; 1 Post
If you find this topic helpful leave a comment.
advertisement

Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's

Thanks

Share this post


Link to post
Share on other sites

Mary, wow.. that's a lot of information to give in a report.. seems like a lot of it the newer nurses should know to look up themselves.. like meds.. rather than have someone telling them.. just a thought.. as for organization of report.. there are several in our unit that use forms.. and write everything down.. one RN uses the abc's which she likes.. a airway (vent, O2 delivery method), b breathing- RR, c cardiac - rhythm, heart tones, etc, d diet, e electrolytes, f family concerns, g mmm can't remember, h hydration, i integument, l iv lines, but you get the point.. to me it's hard to receive report in this method but.. hey.. different strokes for different folks..

me? i use the systems to organize my report and add iv lines... normally everything else is covered under system.. cuz if i'm talking about cardiovascular and they have low bp then i tell them about drips hanging at that time... etc..

i'm fairly new myself, but i'm working towards not writing report down when i get it.. basically everything should already be written down either in the nurses notes or chart.. so why write it down again? i'm not there yet.. but i'm getting MUCH closer .. one of the super experienced nurses does it this way..and while i'm giving her report orally she's flipping through the chart reading the H&P, reviewing the last 72 hours of lab, orders and progress notes etc. then she is able to assimilate what i've told her..and what she's read and ask some REALLY good questions.. things I would never think to tell her .. anyway.. that's my goal..

Share this post


Link to post
Share on other sites

Demographic Information Patient 1

RM# Patient 2

RM# Patient 3

RM# Patient 4

RM#

Age Age Age Age Age

Chief Complaint

Reason for Admission c/o & Reason for admission c/o & Reason for admission c/o & Reason for admission c/o & Reason for admission

Principle Diagnosis

Diagnosis Diagnosis Diagnosis Diagnosis

Comorbid Conditions

Comorbid Conditions Comorbid Conditions Comorbid Conditions Comorbid Conditions

Surgical Procedures Surgical Procedures Surgical Procedures Surgical Procedures Surgical Procedures

ALLERGIES

ALLERGIES

ALLERGIES ALLERGIES ALLERGIES

Code Status Code Status

Code Status Code Status Code Status

Episodic Care

Management Episodic Care

Management

(How many days in hosp) Episodic Care

Management

(How many days in hosp)

Episodic Care

Management

(How many days in hosp) Episodic Care

Management

(How many days in hospital)

Discharge Plan or

Barriers to discharge Discharge Plan

Discharge Plan

Discharge Plan

Discharge Plan

HD/ALOS HD/ALOS HD/ALOS

HD/ALOS HD/ALOS

Plan of Care

Generic Pathway

Pending Actions

Variance to plan

Acute Care Management

(Report only significant changes /information)

Assessments Assessments Assessments Assessments Assessments

Mental Status Mental Status

Mental Status

Mental Status Mental Status

Vital Signs

Times: Vital Signs

Times:

Vital Signs

Times:

Vital Signs

Times:

Vital Signs

Times:

Intake and Output

Intake and Output

Intake and Output

Intake and Output

Intake and Output

Skin Integrity

Skin Integrity

Skin Integrity

Skin Integrity

Skin Integrity

Glucose Monitoring FS

FS

FS FS

Consults Consults Consults

Consults

Consults

Specimen

Test

Labs

Procedures

Treatments

Preps Procedures

Procedures

Procedures

Procedures

Medications

IV

Access Devices

PCA

PD Medications

IV

Access Devices

PCA

PD Medications

IV

Access Devices

PCA

PD Medications

IV

Access Devices

PCA

PD Medications

IV

Access Devices

PCA

PD

Nutrition

Nutrition

Nutrition

Nutrition

Nutrition

Activity

Activity

Activity

Activity

Activity

Teaching/

Learning

Special Needs

Isolation

Fall precautions

Restraints

Constant Observation Special Needs

Special Needs

Special Needs

Special Needs

sorry this was actaully a report sheet I made does not copy well on this site do not know how to copy and keep same format so you can see the report sheet

Share this post


Link to post
Share on other sites
Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's

Thanks

I tried to post my form but couldn't paste it....if you send me a private message, I will get an example to you......

:)

Share this post


Link to post
Share on other sites

I usually just follow our charting...which goes head to toe...I start with important history, then gtts, BP stuff, IV meds, tubes/drains, neuro, cardiac, respiritory, GI, GU, skin issues, family, pain, labs/abgs...short but sweet...

Share this post


Link to post
Share on other sites
Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's

Thanks

OK I HAVE ATTACHED A FORM I JUST MADE BY LOOKING AT YOUR REPLIES ABOVE

NURSING REPORT SHEET.doc

Share this post


Link to post
Share on other sites
Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's

Thanks

I work CVICU and am a new grad (6 months experience). I use Dx, PMH, Allergies, Cardiac, Resp, Neuro, GI/GU, skin, etc. (ex: family), IV, gtts, labs, today (what needs to be done for this shift, or leftovers from the day shift). Works for me.

-PT STICKER-

DX Allergy

PMH

Cardiac Resp Neuro

GI/GU Skin etc.

IV Gtts Labs

TODAY:

Share this post


Link to post
Share on other sites

Thank you for good concise form. It will help me cut down on the rambling some nurses do when giving report. I don't believe I saw a spot for relevant medical history so I will add a row for this info. Thanks again.

Share this post


Link to post
Share on other sites

I can't find how to attach a file to this but if you send me a private message, I can send you the one i use in word. It puts 2 patients on one page

Does anyone have a form to give a comprehensive report to the newer ccu/cvicu nurses? Head to toe,plus meds,AB, IV's

Thanks

Share this post


Link to post
Share on other sites

I REALLY liked the form you just "whipped up" KCIN! I am trying to find a form that is not really for report, but that I can document all my stuff throughout the day on, so that when I go to document in the computer I know exactly when I had a pt visit, gave meds, what FSBS values were, etc...Any help with that?

I did find it unusual that the OP was from almost 10 years ago - wonder what happened?

Share this post


Link to post
Share on other sites

I work in an open heart unit and report was one of the things that I stressed over for the first couple months. I basically use a modified fancas in which I put everything that pertains to cardiac and fluids at the top.

I start off with the history and then I do the following:

IV's - what is running where and at what rate.

Cardiac - heart tones, ectopy/arrhythmias, rate/BP, chest tubes, urine/foley, vascular/pulses, edema, pacer wires, incisions.

I usually talk about the labs and meds at this point.

Respiratory - lung sounds, SATS, vent/O2, rate, suctioning/cough, spirometer

GI - bowel sounds, diet, BM's, nausea, emesis

Neuro - A&O?, pupils, strength, movement

I complete it by talking about the family and visitation.

I think this is a good way to give report on an open heart unit because it addresses the most important stuff first and moves down the line.

Share this post


Link to post
Share on other sites
Guest
This topic is now closed to further replies.
×