What Do You Want To Hear When Receiving Report?

[rebelwaclause]

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.

[rebelwaclause, ASN, RN]

Originally posted by 3rdShiftGuy

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.

See!

That's my point...!

I've got into big do-do trouble relying on a reporter to tell me what I could've reviewed in the patients chart myself. I kinda take most reports as a grain of salt now, I check orders, Kardex's, MAR's and everything in between MYSELF now.

[rebelwaclause, ASN, RN]

Ok...You all are giving me great information.

NancyRN...That's insane. I bet if you start claiming OT for this nonsensical practice, it will end.

What is VERY important to report to oncoming staff, and what is the oncoming nurses responsibility to look up on their own? It shouldn't take longer that 3-5 minutes each patient to relay report, but when oncoming staff chain questions about every little thing, Especially things I would've reported if I felt it was pertinent, I start feeling like I'll never make it home. Sometimes report take 45 minute!

Does it make a difference how report is delivered? We usually gather at the nurses station and grab oncoming staff when they are available (someone else is trying to "grab" then too - This is a frenzy every morning!).

[night owl]

Originally posted by 3rdShiftGuy

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.

I get those suprises all the time

[deespoohbear]

Our noc shift gives several meds at 0600, so they usually know what patients are NPO. I review the Kardex and the MARS, but sometimes a verbal reminder is nice (like the NPO) because first thing in the AM is usually hectic....Here is how is usually give report and in this order:

pt name and room number

age, doctor, BRIEF synopsis of dx

IV left to count (I hate starting rounds with a dry IV bag ) and the rate/solution

any PRN's that I gave

new orders

SIGNIFICANT lab values (like say, hgb of 6)....

lung sounds/bowel sounds if ABNORMAL...

edema if present....

ambulation status for post-ops

any mental status changes (don't need to tell me the pt with dementia is STILL confused, I probably can figure that one out..)

procedures done (scopes, BE, spinal tap) BRIEFLY

That's about it. Since some of us work 12's, I usually get "paired" with another 12 hour person on the opposite shift. If that happens, I really pare down the report to just what happened that 12 hours. It really speeds up report then.....

[Sleepyeyes]

I like our report system. We have the halls divided and a tape recorder dedicated to each section. You can go give report whenever you have a few minutes, you can talk as fast as you want, and the oncoming shift can just stop the tape and write as much or as little as they want.

Rm #, Name, dr, dx, admit date from the cardex.

Then "their story"== ex, "this pt was sent home 2 days ago and came back with different s/s, so that's why you'll find a healing sx incision in the LUQ, in addition to the LLE cellulitis from this admit"

LOC, activity, other dr's consulted & why, test results, tests/labs ordered & results if I have them, ivf, iv sites/date, o2 rate/sat, and abnormal assessment findings ("3+ pitting edema to L great toe")

Individualized details germaine to that pt's care for that shift. Like, please tell me that this pt is a DNR, on fall precautions, or has a sitter every time i get report; it may sound redundant but these things can & do change.

As far as the info on the Cardex--we try to update them each shift, but hey, pt. care has to come first, so if we're swamped, we can't do them.

[rachel h, BSN, RN]

Name, age, dx, brief PMH

info pertinent to the dx (in with COPD exacerbation? I want to know lung sounds, O2 sats, resp. treatments, etc)

Are they A&O? Up independently? HOH, blind, aphasic, etc.

abnormal labs, recent tests/ procedures and results

recent med changes

prns that were given

anything "extra" that needs to be done on my shift

That's about it...

[OBNurseShelley]

getting and giving report isn't too bad for us in L&D, we were 12's and we get a group report and choose our pt's than a more detailed 1:1 reports, since we only have 1 to 2 patients and on rare occasions 3 or 4, report isn't too bad, this is jus L&D we don't do mother/baby on this unit, BUT MY COMPLAINT ABOUT GIVING REPORT IS: when the other person isn't paying attention, like talking to their co-workers, staring off into space, etc, and when I GET ASKED questions THAT I ANSWERED in my report, to me this is a waste of time and if you're not going to pay attention than read the chart yourself!!! ANd learn for yourself the FOB Is an A**hole or the mom is a anxious-worry-wart, etc.....these things are FYI's that can make things got a little smoother. just my pet-peeve!

[BBnurse34]

We pass off report sheets. It makes for a much faster change of shift

[Tweety, BSN, RN]

Originally posted by rebelwaclause

See!

That's my point...!

I've got into big do-do trouble relying on a reporter to tell me what I could've reviewed in the patients chart myself. I kinda take most reports as a grain of salt now, I check orders, Kardex's, MAR's and everything in between MYSELF now.

Abosulutely! I work nights and the day shift can be very very busy. So I always ASAP review my charts for orders and read the md's notes. (Sometimes though this doesn't happen until hours into my shift, but I always try to review the charts to get my ducks in a row and correct any misunderstandings or missed orders.)

[nightingale, RN]

Anyone care to share a report sheet if they have one that can be downloaded(or cut and pasted)?

[nursedawn67, LPN]

Originally posted by nursegoodguy

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...

I do the same thing and want the same thing. If I have been off 3 days or more, I tell the nurse giving report so that if there has been any major changes in the past few days I know about it.

[NancyRN]

There was another thread about "bullying during report" that was interesting. I think that some of the questions asked are more to show off than an actual need for information.

My favorite thing is when a nurse is tossing terms at me and I stop her and say "what's that mean?" and she doesn't really know.