what do you want to hear during report??

*LadyJane* · Apr 5, 2012

Anything current that is out of the norm for the resident is important to know. I don't need to go through report lilke hospital nurses, because we know these residents pretty well, having worked with them for usually a loin period of time. If we have a new admit, we need to know more about them because we may not have time to go read their history in their chart, or it may be incomplete.

We would like to know if they have an upcoming appointment, so we can gather the necessary paperwork, or if they are having tests, or whatever, just so that we can prepare them and ourselves for that.

For many of the residents, the report is, "He's fine".

Jane

Fngrpntsnotasin · Apr 5, 2012

Maybe you would like to know if the residents are crushed meds or thick liquids. I like to know if anything acute going on so I can check it out while I'm down the halls. If they fell or have a new skin problem, just like already said anything different from the norm unless they are new or have been readmitted.

Kittypower123, BSN, RN · Apr 5, 2012

When you are about to get report, try telling the off-going nurse that you don't really know these folks yet and would like any information she/he can give you about each one. Say something like "I know this will take longer, but I don't know these residents yet, can you give me a little information about each one to help me learn?" If you're still on orientation, ask the nurse you're working with to give you info on each resident - that way the off-going nurse won't have to give a longer report. Make notes as you go and throughout your shift. Once you know the residents reasonably well you'll only need report about anything unsual, new issues (skin tears, falls, etc.), upcoming appointments or labs, pending labs, new medications, that sort of thing.

CoffeeRTC, BSN, RN · Apr 6, 2012

If I've been working alot of days in a row, I might need to know a lot less. I work weekends so I need caught up a bit.

New residents I want to know the primary dx (what are they here for) level of orientation, pills whole or crushed, any IVs, Diabetic or not? That's a good start for a quick type of report. The rest I can look up.

Are these nurses that don't want report full time regulars? Not much changes that fast in some LTCs so that I why report can be streamlined.

NotFlo · Apr 7, 2012

In rehab the report I give (we tape report) depends on who the oncoming nurse is. If it's a regular who knows all the pts. my report is much briefer than if it's someone I know is new or doesn't work this floor usually. On new patients I give the full report regardless of who the oncoming nurse is.

If it's a regular nurse who is very familiar with the pts:

room number

name

accuchecks (what they were on my time and a reminder of when the next ones are due QID, BID etc. - I find this helpful because it can be difficult to flip through the MAR on 20 or 30 people to find all your accuchecks...)

last PRN given with times(we give out tons and tons and tons of pain meds and many people want them q4hrs)

any new orders from this shift

how the person did that day...anything exceptional, unusual, etc.

anything they are going to need to know (NPO after midnight for a test/procedure, if they are going out for an appt. etc.)

New pt, nurse unfamiliar with pt:

room number

name

main admitting diagnoses

any "history of" diagnoses that will be impacting care (diabetic, blind, very HOH, hallucinations, CABG x 20, COPD, etc...I wont include EVERY diagnosis in the history as this can get quite long but anything pertinent I will include)

mental status

transfer/mobility status

current code status

any skin issues/dressing changes

if they are a fall risks what alarms/mats/low beds etc they are supposed to have

how they take their meds

accuchecks as listed above

any oxygen, foleys, IVs, PICCs, CPAPs, CPM, polar ice things, G-tubes etc.

def. include if they are on thickened liquids/need to be 1 on 1 for meals/asp. risk

last time for PRNs

any new orders that day

how they did that day as above

anything going on they need to know as above

Okay it sounds long but I do this in a very methodical way right down the line for each pt (I have a sheet I keep adding to all day and use this for report) and taping a full report for 20 usually takes 20 minutes. The short version 10 minutes.

gymrat33, LPN · May 2, 2012

In LTC, I like to know of labs pending, incident follow ups, antibiotics, how their mood was that day (I work in a facility that is strictly Alzheimers/Dementia). Any new orders help as well.