Shift Report Suggestions

[Bec717]

Over the course of the year I have been observing shift report and would like suggestions on providing a concise, but yet complete shift report.

I have seen shift reports where they are tape recorded, an RN runs between a few diferent nurses, some sit down at a computer together, some seem to be a bit unorganized and go off on different topics, and one nurse literally has a full page sheet for each patient and goes system by system as if doing a full assesment, giving information about everything she encountered from moles to hygiene, to what was discussed with the patient from pt ed to their hobbies/interest. (that report took several minutes to complete)

Here is what I do:

Pt's initials, room #, age

Admitting DX

PMH R/T admitting DX or current care

V/S if stable or not

Pain and management

Activity CBR, PBR, up ad lib and if family is there to assist

Any labs/tests and results

Any specific doctor's orders

Overall how the shift went ex. if pt. is resting, comfortable, irritable

I spend 8.5 hrs with a patient and feel like I could go on and on for report.

Please can you offer as an RN what information you need and want and what is not really neccessary so that I can learn to give concise shift reports. What have you found to work for you when you give shift report?

I am doing this on my own, as I was just reflecting back over the past year and everything I observed over the year and want to start getting into a rouutine. Also, I wondered why RN's don't have a standardized form for shift report and instead of giving an oral report, just pass off the written, shift report. Then the report can be put in the shred paper box or is this a HIPPA issue?

Thanks!

[SummerGarden, BSN, MSN, RN]

Try SBAR (Situation-Background-Assessment-Recommendation). Many hospitals and the military use it to give report. It is very easy to do and it keeps you focused. Just look it up on the internet to gain more information. GL!

[Daytonite, BSN, RN]

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.