Tips for giving report and charting??

[Nightingale11]

Any tips on giving report, for example which order to give it in? Also my hospital that we've been doing clinicals at is computerized and I wanted to know if anyone could help me learn to stay organized, as far as faring down vitals, I&O, etc.

[vanlo001]

for giving report: google sbar it is a way of giving report in a standardized way that was developed by kaiser hospitals and is now being used nationwide. sbar stands for

situation: describe what brought the patient to the hospital: ie. "89 year old with history of stroke with slurred speech."

background: describe the patients history. ie. "patient had a stroke 5 years ago and has regained most function. she takes anticoagulant therapy and is a type two diabetic. she was found by her son to have slurred speech and incontinence in her home. she was admitted through the ed and underwent a ct scan last night"

assessment: describe what your physical assessment was, the vital signs over the course of your shift, any lab values, new orders, etc.

recommendations: tell what to watch for- ie. "change in neuro status", monitor ac blood glucoses. think about these things near the end of your shift so you are prepared. mention to the nurse you are assigned with that these are areas you want to strengthen and she will be able to tell you how they do it at that hospital. you can still use this technique even if it's not their way of doing it to keep yourself organized.

here's my worksheet: i developed it so i would have a standard way of looking at my patients every shift, every day.

admit _______ weight _________ pump change: _______ dressing change ________

name: ________________________

dx: ___________________________

age: _____ allergies:____________

line # 1: _______________________

ivf: ___________________________

line # 2: ______________________

ivf: ___________________________

pca: _________________________

basal: ______dem: ______ lo: _____

0800____________________________

0900____________________________

1000

chemo protocol:

_______________________________

neuro:

1100_____________________________

1200____________________________

1300

cv

_______________________________

resp

previous labs

_____

current labs

_____

1400____________________________

1500_____________________________

1600

gi:

______________________________

gu:

______________

ca ____mag_____

phos ___ gluc____

______________

ca ___mag_____

phos:___ gluc____

1700___________________________

1800___________________________

1900

[9livesRN, BSN, RN]

right here in this thread

https://allnurses.com/general-nursing-student/ideas-clinical-cheat-445185-page6.html

you will find one attachement that i have posted where you can find my everyday sheet where i gather my info as well as you will find my sheet to keep up to par of what to do, and when to do... hope it helps