Shift Report HELP

Welcome to AN.com's Psychiatric nursing forum,C.RN!

Our facility went to face to face reporting several years ago, and informational-wise, there is no difference--- you know, precipitating reason for admission, history, behaviors, current status, treatments, medical concerns, etc.

An added advantage is discussing specific areas of concern.

A disadvantage is stragglers and attention-seeking coworkers.

Hope to see you around, C.RN!

A disadvantage is stragglers and attention-seeking coworkers.

Another disadvantage is specific to working 8-hour nights: you will have to kind of report on what happened on evening shift as well. Otherwise the night report will be "Patient slept, patient slept, patient slept..." with no other detail.

Yes, I know saying everyone slept every single night in psych is as likely as snowball fights in Hell.

We do live reports. I keep it simple and stick to the key information: stats, MD, legal status, observational status, code status, allergies, psych diagnosis, medical conditions (if there are multiple, I'll mention the most significant and have them see the EMR for the rest), recent test results (if any) and upcoming tests, and whether they need assistance with ambulating and/or ADLs. Then a brief summary of what happened this shift and what medications were given, and then what they will need to be aware of the next shift. If I worked the night shift, I briefly summarize what happened in the PM as well.

--------------error DD

We have something called roadmaps which contain basic info, such as name, psych diagnosis, doctor, age, and admission date. It once had only precaution levels, which were basically the same on every patient, save for those on seizure, fall, or aspiration precautions, or were on a 1:1 status.

During the week, for 9 1/2 years, I worked all five psych units and would come back to the geriatric unit every weekend. Some nurses did not relay medical results or even any medical status, so, some years ago, I began entering the medical diagnosis under the psych diagnosis on the roadmap. This cued me as to enquire of the medical status when receiving shift report. The practice of entering medical diagnosis caught on and became the standard.

On the adult psych unit, someone began entering the precipitating reason for admission on the roadmap, so I followed suit on the geriatric unit.

The roadmap, once having only basic data, is now a sort of SBAR*, which gives a nurse not typically working the geriatric unit an idea of the patients' reason for admission and medical areas of concern.

There are a number of psych nurses out there with very little, or no interest in, medical. Documenting medical areas of concern causes the oncoming nurses to question the medical status, properly putting the responsibility for an up to date status report on the reporting nurse.

*The SBAR on the medical side is an integral tool. On the psych side, it's cumbersome and virtually useless. They keep them up to date on the other psych units and they're a joke. I've seen entries such as one word, smiley faces and hearts, so that's why I've pushed to have the roadmap as the essential communicating handoff tool.