Published Dec 21, 2002
When signing off duty and giving report about my assignment to oncoming staff, I usually advise of what I did for the patient during my shift (ie...Meds, dressing's, any treatments or pre-op prep), what was abnormal during my shift (including what physician was contacted and what I did as ordered by that MD), and other pertinent information that would be useful to oncoming staff to know.
I've had nurses go on and on about vital signs from 3 days ago that is not relevant at that point. I've heard long drawn out history about labs from a transfusion days ago (no side effects). I've had a nurse get mad at me for not knowing off the top of my head whether or not patient teaching regarding home abx had been taught to the wife. (The patient was a&ox3. Absolutely no learning barriers. I did advise that the patient did an EXCELLENT return demonstration!)
I find every nurse to be a little different in the information they need to feel comfortably informed. Some want the bare necessities, others want a full head-to-toe assessment.
My question is, what type of report do you need to feel informed? Does the shift you work make a difference in the report you want to hear? What information do you think is unimportant?
Thanks for your feedback.
I want the just the essentials. Abnormal VS, prn meds,mental status changes, difficult families, etc. I could care less what the VS were three days ago unless it has something to do with the patient's condition today. Same with labs. If the person's HGB was 13 three days ago, and now is 7 I need to know that. If it is still 13, don't care. Also tell me if the pt is NPO. I don't feel spending 45 minutes in report. We have one nurse who does what you describe. Reviews the labs from days ago and other stuff. I hate giving report to her.....great nurse, but whew....enough is enough....
Just the facts. The birth....but not the afterbirth.
I have been running into such diversity with this. As an Agency Nurse, I have been thinking of writing up a card that I can give to the oncoming nurse.
I get frustrated when they want to review the dang Kardex (I think "they" should review it first).
I am taking a week off and hope to draw up a sample card that I can jsut hand to the next shift for clarification. To me, it should have ABN, Test results and those pending, d/c info, and other POC that are ongoing and need further imporovement.
SKM-NURSIEPOOH, BSN, RN
i agree...give me the essential information for that day's event. giving me a full medical hx isn't necessary unless i ask for it (e.g., if this pt is new to me & have been admitted for several days...knowing the differences or change in status from day 1 until now is important if i'm unfamilar with the case). other than that, i don't think it's necessary to constantly repeat the same things in the report if the status is the same. that just take-up too much time to have to filter the important stuff through.
cheers - moe.
rebelwaclause, ASN, RN
What information should you be expected to "look up yourself?"
(Using you as a question launch, Deespoohbear...thanks for your feedback!)
Deespoohbear, I work NOC shift in which diet sometimes isn't super important (Unless a procedure in the morning, NGT, Tube feeding, etc). Most (not all!) patients don't ask for food in the middle of the night. I understand your point, and I make it a point to advise of diet status, even though it didn't apply to me during my shift. But if the kardex is updated, should I read everything that is already written there to oncoming staff?
Now that I think about it....Kardex's and the lack of it being updated is an entirely new topic!!!!
I must admit, all I want are this:
Why is the pt here.
What has been done.and how did the pt react to what has been done
What needs to be done by me.
What is pending and what is not pending.
Now, I work ER, so if a patient stays over a day that is definitely news. and I must admit, I am a chart reviewer- so I look over the chart and get most of the info from there....I too, get annoyed when people start to ask a million questions regarding social history or what not. the pt is here for a broken leg- and we have a nurse who asks: Does he have a hx of PUD? Oye Vey.
I work LTC... I made up a report sheet with everyone's name on it and included essential info such as who gets crushed meds, diabetics, thicken liquids...
I don't really like going over everyone's names and saying this one's ok and that one's ok and so on... just tell me who's not ok! I keep my report sheet right on my cart so if I run into anything I can jot it down, including if I am missing a med and have to order it, any new orders, any illness, anyone out on pass... etc
Probably it's a lot different in LTC where you expect most of your patients to be relatively stable...
IN LTC, Just give me the highlights please...
Tweety, BSN, RN
Diagnosis, history, presenting symptoms and current symptoms, adnormal findings on head to toe assessment (i.e. if lungs are clear and bowel sounds present no need to tell me all that stuff).
I can look at the med sheet and tell what meds they are on, but please tell me the prns you gave.
Any new orders you didn't get to. Any tests and procedures they had done, or have yet to get done.
Basically, I don't want any surprises in the middle of my shift, i.e. he should have been npo after midnight for labs, etc.
But I don't want to hear about the insignificant details, or all about his personality, what he did and did not eat, etc. Just important stuff.
Where I work, all the nurses have the bad habit of actually reading the trifold to the oncoming nurse! It takes an hour to get/give report. I've tried to break this trend, but it seems to be deeply embedded. If I don't READ the trifold to my replacement, she'll start hammering me with questions such as: what were his Vitals? What's the date on his Heplock?"until I have to pick it up and read everything to her.
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