Taping Report

TexasPediRN · Jan 10, 2006

Taping- my worst fear..

For one week til I got used to it.

If your hospital uses Kardexes- start with that. Pt name, birthday, admission date, diagnosis, allergies, etc. Then you can move onto meds, and in this section add any new meds or changes with the patients meds. Then talk about the Iv, the site..when a new bag was hung, etc.

I was horrible at taping report at first. I paused constantly. Then my friend, another nurse on the floor, came in with me. She opened the kardex, told me to keep taping report- and while I taped pointed every single section out to me, so I didnt miss anyything. It really helped me to develop a good flow when it came to taping.

I also recommend listening to the other nurses reports-see what they say, and how their report flows.

I promise you you'll get it, it just takes a little time!

Also- in school we practiced with a tape recorder, and then listened to ourselves and talked about what we forgot. It helped.

Good luck!

Daytonite, BSN, RN · Jan 10, 2006

You want to give the name and room number of the patient, any very special orders (such as NPO, absolute bedrest, turn q2h, special diet) and then proceed to give a synopsis of what happened with the patient during your shift (or time with them). Mention which labwork and x-rays were done and specifically any significantly out of the normal results, including fingerstick blood sugars of diabetics. Mention if the patient went to surgery or had some procedure done at the bedside and how they are doing. Mention if you had to call the doctor, why, and what the doctor said or ordered (new or discontinued medication, new or discontinued treatment, new lab or testing orders). Mention any significant complaints or problems that came up that you had to deal with and the outcomes. Mention anything the next shift needs to follow-up on after you are gone.

I believe that years ago when I was new at this, I made a generalized list of items to report on during shift report in what I thought was an order of importance. I kept that list in front of me as I taped to help me. You might want to do something similar to help you organize your report as well.

I'm attaching a copy of the report sheet I use when I take report as I come on shift. I will refer to it when giving report as I tend to write down all kinds of information on it over the course of my shift. Feel free to use it, improve on it, whatever gets you through your shift.

[ATTACH]5032[/ATTACH]

WAstudent · Jan 10, 2006

Awesome! Thanks!

sharonanytime · Sep 27, 2008

Please let me know how I can attach a file in reply to this post.:lttang:

Mia123 · Sep 28, 2008

I am precepting in ICU, and I have to give report on my two patients. In ICU, we only have two patients and the reports tend to be more in-depth than on a med-surg floor. I made a worksheet (but did not save to word) and I fill it out when I get report, make notes throughout the day, and just give report that night from the worksheet. It makes it easy and everything I need is on the sheet. These are the catagories:

General: Name, DOB, admitting dx

History: Pts history

Neuro: LOC, etc

Cardiac: telemetry, HR, etc

Resp: lung sounds, cough, Oxygen, etc

GU: foley, incontent, color of urine, output

GI:

INT: skin condition, breakdowns, areas to watch, etc

IV: location, infusing, patent, fluids, rate, etc

Meds: what they are taking and what time, how they responded, what is due next (then on the back of the sheet, I write down all the meds I am giving and look it up in the drug book and write what it is for, S/E, that kind of thing)

Treatments: wound changes, breathing treatments, etc

Labs: any abnormal findings or labs that need to be drawn

Tests: tests the pt took that day, any findings, what tests are scheduled

Of course, this can be taylored to your own client or what area you work in. I just find it good, because all the info is right there on my sheet.