Time to read the chart, MD notes?

MunoRN, RN · Apr 2, 2011

I know this is a little off topic, but you don't talk to the nurse when getting report? I would think that might be part of why you don't feel like you get a good report. I know that not every Joint Commission recommendation has to be followed, and there are certainly some we don't follow for good reason, but opportunity to ask questions during report seems like a no-brainer. My state takes the JC recommendation a step further and considers a recorded report to be patient abandonment except in long term care and mental health.

AKA_Glamour_Pearl · Apr 2, 2011

I know this is a little off topic, but you don't talk to the nurse when getting report? I would think that might be part of why you don't feel like you get a good report. I know that not every Joint Commission recommendation has to be followed, and there are certainly some we don't follow for good reason, but opportunity to ask questions during report seems like a no-brainer. My state takes the JC recommendation a step further and considers a recorded report to be patient abandonment except in long term care and mental health.

Wow! I didn't realize this. I've been in two clinical settings where tape recorded report this is common practice. :uhoh21:

stellaRN1983 · Apr 2, 2011

Wow! I didn't realize this. I've been in two clinical settings where tape recorded report this is common practice. :uhoh21:

Yes I talk to the nurses after listening to recording and checking orders and medication times.

MunoRN, RN · Apr 2, 2011

The Joint Commission National Patient Safety Standard on Communication:

"During hand-off communication, clinicians need an opportunity to ask and answer questions. This part of the requirement may affect the way nurses provide their change-of-shift reports. Audiotaping these reports isn't acceptable unless the process includes a way for the nurse who is receiving the report to ask clarifying questions—which seems unlikely."

http://www.modernmedicine.com/modernmedicine/CE+Library/JCAHOs-Patient-Safety-Goals-Part-1-A-practical-gui/ArticleStandard/Article/detail/388219

My own state's BON sent out a revised interpretation of patient abandonment a few years ago that specified patient abandonment includes handing off a patient without establishing that the receiving nurse has not only received the report and has no questions. We discovered this we we tried to switch to a faxed report between floors with an optional phone call for questions. Our BON said that we couldn't just assume that because we didn't get a phone call from the receiving floor that there were no questions, we had to make the call confirming receipt and understanding of the report mandatory, otherwise it would be considered patient abandonment if the handing off nurse didn't confirm receipt and understanding of the report either by phone or face to face.

MunoRN, RN · Apr 2, 2011

Yes I talk to the nurses after listening to recording and checking orders and medication times.

Then what's the point of a recorded report? Wouldn't it be easier to stop and discuss something when it's brought up rather than trying to remember your questions later? I remember the days of recorded reports and the handing off nurse would have to wait and sit there while I listened to it, she was supposed then answer questions but it was pretty universally understood that if you asked questions after the taped report that you were being rude, so it never really happened. Thus the current preference for interactive reports. Having done both, I can tell you that there is a huge difference between the two.

Push for a switch to face to face and you'll get more of what you are looking for out of it. You are interested in the overall medical progress and plan, some nurses don't want to be bothered with information that is "out of there scope" so a one sided , generic taped report will often not contain this information, but with a face to face you can easily that component to the report you are getting, making it more useful to your specific needs.

danh3190 · Apr 2, 2011

We always tape report. I think it's rude not to. However it's also rude for the departing nurse not to ask the oncoming nurse if there are any questions.

Back to the OP comments... I get a lot out of reading MD notes on the rare occasion that I can read them. I wish I could get my butt in to work an hour early so I'd have the time to go through them all.

neuroms · Apr 2, 2011

I agree that Dr's notes have a lot of great detail that can help care for a pt, but $20 says you won't find out whether patient X had bowel movement last night or the smell, color and consistency of said bm in those notes.

bennyRN · Apr 2, 2011

I agree with the OP, you learn so much more about your patients from reading the MD notes, and by the end of 3 shifts with the same group of patients you feel like you know them iinside out. BUT, whether or not you have time to read the notes is a whole different story - we're allowed to clock in 15 minutes early but getting myself there that early is a whole other story! And finding time during the shift to read the notes is pretty impossible sometimes. Reading those notes and knowing whats going is so valuable, having a strong knowlege of your patient's pathophysiology and medical treatments allows you to provide much better care for your patients. We took all that painful chem, pathophys, microbio, pharm etc for a good reason!!

We give verbal reports where I work, I cant even imagine getting report from a tape. And having it be considered "rude" to ask questions at the end of a peport? Thats absurd and dangerous for the pt's! I've gotten so many crappy reports where I've had to ask the RN pretty much every piece of info i needed to know...i cant imagine getting it via tape and not being able to asking questions.

makes needs known · Apr 2, 2011

It seems like there is never time to read the chart, and no private, quiet area where you can read it without being interupted to get a box of kleenex. I like to read the chart, sometimes when I ask the previous nurse she is a little vague about patients admiting dx. I understand why she is vague, we are understaffed.

Chin up · Apr 2, 2011

Instead of rushing to work, or having to read, Md notes, maybe the bar needs to be raised on giving report. You used the word sketchy, the nurse giving report should have an expectation, maybe an audit tool of some kind to help with the essentials of report. Also, if recorders are used, the nurse should be available to answer questions once you have listened. Then you can use your notes, to question further. Years ago, everyone taped report and it only served the nurse leaving for the day. They did not have to stay until report was heard, and many hurried through theirs, leaving out crucial information. Some would even conveniently forget a difficult patient or two and laugh it off when it was brought to their attention. One nurse was famous for mumbling quickly through labs and things she never took the time to know. Sometimes, nurses do forget what they want to tell you. Talking to a tape does not have the remembrance effect, as talking face to face. When reporting face to face, a simple word, can trigger a whole incidence that may have been omitted during a taping. Face to face, I believe is safer, much more complete and also helps with skills. Two nurses bouncing off each other, reinforces the when, where, why's and how's. Speak to management about this issue, having a solution or two, already to go. Peace!

I acknowledge all the great reporters on tape out there! Unfortunately not everyone has the ability, and some just want to get out as soon as possible.

NicuGal, MSN, RN · Apr 2, 2011

I can't imagine having taped report anymore! And if you have patients with lines, aren't you supposed to go over them with the offgoing nurse? It honestly doesn't take anymore time than face to face, esp if you are hanging around to answer any questions.