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nursemike630 nursemike630 (New Member) New Member

Struggling with report

Med-Surg   (2,161 Views 10 Comments)
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Hi everyone

I am a new grad RN working on a med surg telemetry floor. I have been on orientation for 7 weeks with 5 to go. I am still struggling with report. I come in an hour early to look my patients up. I feel I am writing down too much without truly comprehending the big picture.

  • how do you prepare yourself before report?
  • what do you use to organize yourself throughout your shift
  • and most importantly, what is your advice for giving report to the next shift. I know time management comes with time and I already feel myself improving a bit. I'm ok being constantly busy and figuring out how I'm gonna accomplish everything. But I feel so defeated at the end of my shift not giving an adequate report. I don't have time most days to regather my thoughts to try to think about what I'm going to say in report. Almost every time I leave out important information that when my preceptor adds at the end, I think to myself 'Why wouldn't I have said that' it even worse, 'Why didn't I know that about my patient and you did'. I feel especially useless if I'm giving updates to the nurses coming back at night who handed off the patients to me. Im not giving them a full report because they already know the patient.

Any advide would really help me. This is what is worrying me most about coming off orientation.

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I feel your frustration. We have all been there. The most important component for keeping everything organized for me is an organized set report sheet and writing down details throughout the day. You can google nurse report sheets. They have all kinds to print. Just need to find the one that works best for you and your environment. Once you find one that works report will become easier and smoother the more you use it.

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The funny thing is that all nurses like different information in their reports. Most important, we have alot to do so making the report short but sweet is critical. Giving the lifetime medical and personal hx of the patient (seen this) is not important unless it's crucial to immediate care. Personally, there are very little labs that I want reported to me from night shift. The new ones are posting around the start of my shift anyway. Only labs that are pertinent to the care they might need in first hour of shift matter to me since I will absolutely be looking at them right away anyway. From my pov I want to know dx, pending procedures, possible discharge if that day, significant events overnight, if diabetic, diet, any out of normal vs and if were treated overnight, dvt prevention item, rtf. Then a quick knowledge of transfer needs, what lines they have, running fluids etc. We also do dual check off at shift change for all drips, tpn and similar items. If these are done quickly each patient can be reported on within a few minutes. Pain discussion can be included in your introduction to the patient during bedside report. Frequently if they have surgical dressings or such which can be quickly seen (jp drains etc), a quick peak is good as you will be looking at them during your assessment anyway.

I know this seems like alot, but it really can be done quickly in time.

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I see a lot of different reports that eventually end up with same information that I can extrapolate information form. As a nurse when someone is giving me a report with information I am going to use and take over the cares I want timely and relevant info for that patient.

So when you think about the patient think about the patients situation, background, your assessment of them and any recommendations

Situation:

Background

Assessment:

Recommendation:

Your assessment should be the biggest one you speak of this example of included items is not all inclusive.

Situation you want their name, Dx, admit date, code status SP OR or future OR dates

Background you want brief Hx of the big issues i.e. diabetes/HTN anything that is chronic, I do not care if they have had a sinus infection unless it pertains to this episode of care. Any barrier to learning/culture issues is patient confused?

Assessment: is the big one I want resp status, skin, neuro, current labs abnormal results, pain, current PRN Rx and when they last took, how are they sleeping.

Recommendations: Think interventions needed i.e. teaching, possible DC in 3 days they need to be educated about HTN, orders that have not been completed (think DC) .

I suppose if you break it down into 4 specific issues above and just focus on one at a time you should have a report that takes no longer than 3 mins per patient and hits all the target areas.

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I will just add a few things. You can add a blank section to your brain sheet, or whatever you use, and there you can put updates so you remember to tell the night nurse at change of shift. You work on a tele floor so most if not all of your patients are cardiac so that should be where most of your focus is. History like appendectomy 20 years ago is not important, for cardiac patients any and all cardiac history, DM, kidney problems/HD these are important things to know in terms of history. Next what brought the patient in to the hospital and how they got to your floor. Then head to toe, I start with neuro and end with skin this way you won't miss anything, you are streamlined and it will also help jog your memory of things you may have forgotten. Then I do lines/drains/drips and then I do the plan for the patient and thats it. There will always be nurses that ask a million questions about things that are not important and saying "I don't know" is fine, if they want to know they can look it up themselves. You will get it over time but I find going head to toe is best.

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I like organizing my report like this:

1) room #, patient name, age/gender, date of admission, isolation precautions, code status, provider group following them.

2) admitting dx; other hospital problems we're treating

3) course of hospitalization (any notable procedures, surgeries, or other hiccups during their length of stay); what happened to the patient today

4) health history

5) assessment data; at bare minimum, I include neuro status (A&O, CVA hx, baseline tremor, etc), CV status (rate, rhythm, BP, heart sounds), pulmonary assessment (lung sounds, chest tubes w/ drainage amount, RA or O2), GI/GU data (diet, fluid restrictions, ACHS, Foley), skin (skin breakdown, wounds, CHG bath) and mobility (independent or level of assistance with ADLs), IV access with running gtt rates, pain assessment/interventions, pertinent lab results

6) plan of care, including possible discharge plans or future procedures/surgeries; for this part, it's helpful to look into the provider's most recent progress notes.

I think the way you arrange your handoff report also depends on the unit you work in. I work in a cardiac PCU, so I ALWAYS include a detailed cardiopulmonary assessment. This setup up isn't perfect, but it works for me - it also helps me see the "bigger picture" as you said.

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When you look up your patients, look at the same thing the same way every time.

For example, here is how I do it:

1. Why are they admitted and who is the admitting doc?

2.When were they admitted?

3.What are their recent orders?

4. What is their dietary status (NPO etc.)

5.What is their ambulatory status?

6.What recent labs were done? Write down ones that deviate from normal. Even if you don't know what they all mean...write down ones that are flagged as abnormal.

7.Check the meds and see what is due and write them down. Check allergies

8. See if they are on any IV medication and or need glucometer checks.

9. Look up any imaging that was done.

10. Read the last dictated provider note.

At the very least if you look in the chart the same way every time, before long it will become second nature. You can give report in that way as well. "80 y/o patient admitted with pneumonia under Dr. so and so, recent orders include...diet status is...recent labs are...etc.

If you know what you are starting with, you know what will have changed before you leave.

And even if someone "already knows the patient" I think they should listen to you give a full report anyway. The most dangerous thing anyone can do is think that just because the patient was one way on their last shift they will remain the same on the new shift. :)

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Giving report takes some time to learn and feel confident. Here's what I do:

- When I look up my patients, I write down: name, age/gender, admit date, code status, allergies. Then I look up meds and morning labs. If I have time after I've done that for everyone, I also scroll through the orders and scan the most recent Progress Note or H&P to get an idea of what's going on and what the plan is.

I give report this way:

- Demographic info (name, age/gender, admit date, Provider/Team, code status, allergies, IV access)

- Admission reason, short summary of what we've done, and what the plan is

- Quick medical history of pertinent info (DM, HTN, COPD, etc...stuff you need to know when you're caring for the patient)

- Any labs/meds/protocols they'll need to deal with in the first couple hours (ex: K was 3.4, I gave IV K, so you'll have a repeat level due at xx:xx time)

- Quick review of my head-to-toe (not everything, but basics: Alert/Oriented x4, 2L oxygen c CPAP at night, last BM, how they void, skin issues, mobility, pain, any abnormal findings, and any abnormal vitals) They're going to do their own assessment anyways, and they can look at my charting to see what I found.

It usually takes less than 5 minutes to give report. I made my own report sheet that works with how I think, and it keeps this info organized for when i have to give report at the end of the day. I also use different colored pens to update my paper as the day goes on. That way, if I'm just giving updates to someone, I really only have to worry about the stuff written in pink.

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Hi everyone

... and most importantly, what is your advice for giving report to the next shift. I know time management comes with time and I already feel myself improving a bit. I'm ok being constantly busy and figuring out how I'm gonna accomplish everything. But I feel so defeated at the end of my shift not giving an adequate report. I don't have time most days to regather my thoughts to try to think about what I'm going to say in report. Almost every time I leave out important information that when my preceptor adds at the end,

At the end of your shift, are you tired or hungry? You can't do much about being tired, but you can be sure that your blood sugar is normal.

I found that quickly drinking a nutritional supplement (Ensure, Boost, Glucerna, etc.) about an hour before the end of my shift made a huge difference. I can drink down a bottle of Glucerna in less than 2 minutes.

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