What is the best way to take report. (New Nurse)

mommatrauma, RN · Jul 10, 2005

I am a new RN starting Orientation on Monday!!! I have always tried to learn from all my preceptors during clinicals the best way to stay organized and on task during the course of the day.
I have been looking for the best way to take morning report, whether it be a standardized form that has all of the important information categorized (vitals, labs, tests, etc.) and ready to be filled in or just a blank sheet of paper divided into the number of patients you might have.
Any help would be appreciated. I would like to start out somewhat organized with a system that actually works!
thanks......Pat

Listen first..then ask questions..I can't tell you how many times I try to give report and the nurse I am giving report to starts asking 50 questions that I would have answered before she had to ask if she'd just let me get through my report...higher chance of forgetting to tell something important with more interruptions...

KaroSnowQueen, RN · Jul 10, 2005

When you get your cardex, make a list straight down one side or on the empty side of the page:

A&O:

HEART:

LUNGS:

O2:

IV:

IVF:

PPP:

EDEMA:

BS:

F/C:

ACCUCK:

SKIN:

ACTIV:

Fill in the blanks as you go thru.

Across the page write down:

ADM DX

TEST/PROCEDURES;

SYMPTOMS:

(and anything else pertinent, NPO, etc)

When you do your assessment later, update your notes in a different color, and add any new orders, results, anything important in your new color.

When you GIVE report at the end of shift, you will have a coherent, system by system report of your patient. You will be able to make sense of the report you give and receive, and hopefully the oncoming nurse will appreciate your efforts!!!

Example:

A&O: x2 person/place ADM: COPD

HEART: SR c 1 AV block pulm funx test yes

LUNGS: dimish, rhonchi upper prod yellow cough

O2: 3L 94% desats 82 on r/a wife in ICU

IV: 22 lt a/c kids in from california, staying at

IVF: d5 1/2 c 20 K @ 100 Holiday Inn 555.8833

PPP: +

EDEMA: 1+ BLE

BS: + BM 6TH

F/C: urinal

ACCUCK: ac/hs sl sc 144

SKIN: scattered bruising, digits cyanotic

ACTIV: up ad lib

Sunnibee · Jul 10, 2005

KSQ has a good strategy! I have seen some folks make a template of that report sheet and put 4 to 6 on a page, then run it off in bulk at Kinkos. That way they dont have to write it constantly, and if they have the same pts next day they can just add new things. In critical care it is actually easier, just write down your body systems and add lines and drips at the bottom; most of ours have foleys and are just lying there!

UM Review RN, ASN, RN · Jul 10, 2005

We use a template such as described above to give written report. To speed up the process, I even stamp each of my report sheets with the patient's Blue Plate--less writing and I don't have to worry about spelling.

HyperRNRachel · Jul 10, 2005

When you get your cardex, make a list straight down one side or on the empty side of the page:
A&O:
HEART:
LUNGS:
O2:
IV:
IVF:
PPP:
EDEMA:
BS:
F/C:
ACCUCK:
SKIN:
ACTIV:
Fill in the blanks as you go thru.
Across the page write down:
ADM DX
TEST/PROCEDURES;
SYMPTOMS:
(and anything else pertinent, NPO, etc)
When you do your assessment later, update your notes in a different color, and add any new orders, results, anything important in your new color.
When you GIVE report at the end of shift, you will have a coherent, system by system report of your patient. You will be able to make sense of the report you give and receive, and hopefully the oncoming nurse will appreciate your efforts!!!
Example:
A&O: x2 person/place ADM: COPD
HEART: SR c 1 AV block pulm funx test yes
LUNGS: dimish, rhonchi upper prod yellow cough
O2: 3L 94% desats 82 on r/a wife in ICU
IV: 22 lt a/c kids in from california, staying at
IVF: d5 1/2 c 20 K @ 100 Holiday Inn 555.8833
PPP: +
EDEMA: 1+ BLE
BS: + BM 6TH
F/C: urinal
ACCUCK: ac/hs sl sc 144
SKIN: scattered bruising, digits cyanotic
ACTIV: up ad lib

Kids in from California ........ :chuckle :chuckle

JVanRN · Jul 10, 2005

Kids in from California ........ :chuckle :chuckle

Huh?

HyperRNRachel · Jul 10, 2005

Huh?

Read the example.

JVanRN · Jul 10, 2005

Read the example.

I did...I don't get it. I mean I get what you posted in response but I don't get the example. It's okay...don't explain. I'm dim right now and need to go to sleep everything is flying over my head right now:rolleyes:

mommatrauma, RN · Jul 12, 2005

I did...I don't get it. I mean I get what you posted in response but I don't get the example. It's okay...don't explain. I'm dim right now and need to go to sleep everything is flying over my head right now:rolleyes:

I think maybe a typo in the example...