Standardized Hand off?

[goatmountain921]

Hello everyone! I'm brand new to the site. I'm a new nurse on a med surge floor, been off orientation for about 3 months. One thing I've had trouble with is hand off. Sometimes when I receive report the information is all over the place. Sometimes I'll go into a little more detail and I can tell the other nurse is getting annoyed. Other times I wont go into as much detail and I can tell the other nurse thinks I'm giving a shoddy report. I wish there was a standardized way to give report (besides SBAR), like a checklist or something that I could hand out. Maybe if a nurse wanted to go into greater detail than what is on the checklist then they can add what they want at the end. My unit supervisor said I should look into this further, and perhaps present what I find at the next staff meeting. I know a lot of nurses have a certain way of doing things and there would be a lot of push back, especially coming from a newbie like me. I was wondering if anyone had any ideas on the subject, if so, I would really appreciate it! :)

[brillohead, ADN, RN]

I spent my first several weeks tweaking my "brain sheet", taking note of what people did/didn't tell me or ask me in report.

I also set up my sheet (which I fold into quarters to fit into my pocket) so that I can make all my notations when receiving report in one place, without having to unfold / turn over my brain sheet, flipping back and forth and trying to figure out where each item is. This way, no matter what order the other nurse is giving me the information in, I can easily jot it all down without having to write notes all over the place.

This is what a typical report looks like from me (general medical / cardiac telemetry unit):

Patient Name, Room Number

___yo male/female

Admitted on for

and how that problem is being managed currently

History of

Isolation Precautions, if any

Accuchecks - AC/HS, Q6, None

Code Status

Telemetry - yes/no and typical rhythm

Oxygen running at ___LPM via NC/Venti/NRB

Patient is / is not normally on oxygen at home

IV#1 is in running at (or saline locked)

IV#2 is in running at (or saline locked)

Patient is on diet / fluid restrictions

Activity/toileting (stand by assist, 1person, 2person, independent... toilet, bedside commode, bedpan, Foley)

Home: also note if there is a Legal Guardian, and any funky family dynamics going on

Procedures planned for the next day

PRN meds available and when last given (things like Ativan, pain meds.... not Milk of Magnesia, etc.)

Any relevant lab results

Anything that I think needs to be brought up in interdisciplinary rounds that day (I work nights, so non-urgent discussions with Pharmacy, Dietary, Social Work, Case Management, and Physician all get passed off to day shift to be handled)

Hope this helps!