Taking/Giving Report

We were instructed to use the SBAR format for report or when calling a physician. Most of us, however, just tell if the pt is A&O, ambulatory, how they void, any tests or procedures recently done or scheduled, breath sounds, bowel sounds, IV site, and last prn meds. You'll get more comfortable as time goes by.

See this link or google it if you want more info.

http://www.medleague.com/Articles/medical_errors/sbar.htm

I am a nursing student as well, 4th semester w/ med surge clincals. I made a format of points so I could stay on my game here's what I use

• Medical Diagnosis
  
• Code status
  
• IV fluids, rate and type
  
• Any special equipment ex. PCA
  
• Medications
  
• Plan of care/nsg. dx
  
• Diet
  
• ADL's
  
• Any procedure to be done (accuchecks, labs)
  
• Patho of disease
  

let me know if you like it

Hello, I'm new to this to so bear with me. I actually just got this thing at a job fair the other day and it's proved to be very helpful. She made it up and it helps to keep all the important patient info in one place... keeps you organized. The website is www.RNReportCard.com.

I wanted to give an update on my problem, after everyone was so good about making suggestions. I tried this thing someone suggested here, the RN report card. I've been using it for about a week now and its been really helpful. It just helps to keep everything organized so I'm not fumbling when someone asks me a question. My only complaint is "Where was this thing 6 months ago!!" Check it out, the site is www.rnreportcard.com