shift report

We use SBAR report sheets which we update as the shift goes along. We keep the same sheet from shift to shift, writing in pencil, until the patient is discharged or until the sheet just really needs to begin anew. It's much easier to provide updates that way.

I noticed this was one of my weaknesses in nursing school. So I made head to toe report sheets, which made getting and giving report much easier. They go in order, so on the top is the name, diagnoses, history, allergy, age. Then it goes from neuro/orientation, lungs, heart, bowel, GU, skin, etc. On the side are the labs. And then I make notes in the empty spots about plan of care, etc. I didn't have my sheets one day and getting/giving report was just awful!

If everyone on your unit uses the same report sheet, I would make sure to use the same one. On my unit we all use the same SBAR sheet, and I eventually just get used to what everyone is expecting to hear. I write everything at the beginning of the day in one color & as things change write the changes in another color. I write down the patient health history on a sticky note & then we just pass it along back and forth between nurses. This is very time saving since so many patients have a health history a mile long. I think that it just gets better with time. GOod Luck!