Shift Report Suggestions

i gave the basic identifying information about the patient (name, room number, doctor) and then pretty much hit on what you would call the nursing problems. you might call them the nursing diagnoses. you don't have to be that formal in report though. if they have ivs running they have fluid problems, so i quickly run through any problem or changes in respect to this on my shift (change in iv orders, messed up electrolytes, edema, wacky i&o). if there is a skin problem that we are doing treatments on i run through any order changes or the status of the wound. i address anything unusual that occurred with regard to the management of that patient during my shift whether it involves having to call the doctor for something, new orders written by the doctor, the patient was given a terminal diagnosis, plans to discharge in the morning, need to be npo for surgery tomorrow am, some fracas that occurred between the patient and visitors or someone of the staff, a med error, a missed test, and any number of things that could have happened. i don't go over orders that can be found on the kardex (diet, activity, labs, meds, treatments). a report should be about what has happened during my time with the patient. the only exceptions are memorable happenings from other nurse's shifts that really need to be passed on as well. sometimes a patient has some odd, unusual or out of the unit routine treatment or doctor's order that really needs to be pointed out so it doesn't get overlooked.

fyi. . .sbar is a nice system. it is the nursing process (problem solving process) stated in different language. it was designed as a guideline for organizing information in order to help you make decisions and help express your needs. the sba part of it is about assessment, step #1 of the nursing process. the r part has to do with decision making and that is step #2 of the nursing process. i say that there is more to shift report than informing oncoming staff about changes in patient's conditions. goofy and monumental things happen that have to be passed on. a patient hitting the call light every 15 minutes during my shift is something i think the nurses following me might want to know.