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?
Specializes in CVOR,CNOR,NEURO,TRAUMA,TRANSPLANTS.
I can say this is why I moved down to the OR from the floor. Report from the floor from the offgoing shift took and hour and by the time we got on the floor we were so backed up from listening to their trival crap of thier day of events which very little had to do with patient care. We worked second shift and our report to us almost at times took and hour which is rediculous and we were running out of the report room to get our day going and 90% of the time completing what first shift didnt do. You all know the storys too many chiefs not enough indians.
By the time we got our shift off and running we were behind and busted every hump possible to catch up and stay ahead if we could. At the end of the night our report lasted a total of 30 minutes and it was filled with everything done during both shifts and what is to be done during 3rd shift and it was filled out on the patient census and with all needed info on the sheets and a overview done during report.If there was a change in anything other than (hey they're in the hospital for a reason) it was on the sheets. VS, labs due, abnormals and drsg changes where on the sheet, also if there was a consent form to be done and a prep.
Now in surgery I love it. When I drop the patient off in post op I giveALLERGIES:on or off o2,cardiac status,pulse points and marked.Surgery done, Surgeon, Anasthesia type, tolleration, VS, drsg and where and if any change and type marked, if family is here and reports to family given and if we have attached something to the patient that needs to be monitored and how it is to be monitored, and what room I will be in and what room the Dr will be in if complications occur. They seem to like what info I give its too the point and doesnt take a month to give it.
Just the essentials please...I don't want report for an hour on 3 kids...all that are feeders and growers! A critical vent or chronic kid, sure lay it on me, but forget all the other stuff. I have had nurses go on about what came out of a kids nose and not tell me, oh yeah, he grew out gram neg rods by the way from every body fluid we sent. Good grief! And I hate those people that expect you to spew out the whole HandP when you have only had the kid for 4 hours! And really, after the kid has been here for months, who cares how much bowel they lost...just tell me if they still have their ileocecal valve and whether they dump or not!
Rats Sleepyeyes...I thought this was a great idea too. We tried it, and failed miserably. I'm off at 0730, new staff starts at 0715 (if they are on time...Ooooo...LATE STAFF...ANOTHER THREAD!). There was times up until 0800 that we would have to ask those who have already heard report to come relieve us. I guess their thoughts where they waited until all staff members had arrived before listening, then EVERYONE heard report on everybody, so all would be informed. I loved the tape recorded report, but unfortunately too much overtime was being given, so managers dismissed it.
no wonder it didn't work; the implementation was a lil screwy to say the least!
the whole point of having a few tape recorders was so that after report, the prior shift is immediately relieved upon getting report, and there's not that gawd-awful one-hour wait for the patients to get some pain relief or whatever--the whole point of doing it this way is, there's always a nurse covering that assignment.
Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.
We are required to do chart checks every shift to cut down on info that might be missed in report from the previous shift. This helps a lot, because there are people who consistently leave stuff out. Things move so fast on our floor that kardexes aren't even used any more because it's so much trouble to keep updating them.
I am one who probably gives too much info to those less anal than myself. . hehe.
I like to do a head to toe systems review of abnormals then labs, IV's and POC for next shift. If the oncoming nurse knows the patient we don't get into ancient history. I've learned to physically review chart orders during report to avoid missing something.
I am bad about leaving 'little notes' for my docs too...taped securely to the chart so they don't accidentally fall off. .
I prefer too much info to not enough when I recieve report so I try to do the same in ICU...but on the PCU it becomes report on major points...or we're way OT...sometimes I had trouble switching gears between ICU and PCU when I floated.
BadBird: Your list was great. I give report pretty much the same way. I add: Mobility, Diet and tolerance, withe Skin, add edema and treatments for decubs, Labs: abnorms and tx for them, PAIN: meds for it, last dose given, effectiveness, etc., Family: if there is any necess info such as wife gives AM care, etc.
I work days, 12 hr shifts. We recently have been concentrating on slimming report time. We've tried various things and are doing pretty well so far. We divided up the floor into three groups representing rooms (1st group is approx the first 10 rooms and so on. Of course it can vary somewhat with census.) The on-coming nurses sit in that group's report area and it's the off-going RN who moves to the areas as needed to give report. RN's MUST give report (not LPN or NA) and the LPN and NA who is going off-shift covers the floor. On-coming LPNs and NA must hear report along w the RN. That way some delegation can begin immediately. Report begins promptly at 0645 and we really strive to end at 0715. Not too bad.
I agree w you guys that a pet peeve is the nurse who goes on & on & on about the size, shape, odor & color of each BM, yadda, yadda, yadda......PUH-LEEZE. Just tell me if they pooped or not & MOVE ON. I am becoming notorious for saying "OK...gotcha...I only have 12 hrs, so let's move on!"
I am orienting another RN, so I have written down the list like BadBird's, and gave it to her to use for report to try to keep her on-track. She would be one of "those nurses" if I allowed it. I listen in to her report and I am always saying (with a dramatic look at my watch!) "OK! What else??" (I am SUCH a "B"!!!)
RN's MUST give report (not LPN or NA) and the LPN and NA who is going off-shift covers the floor. On-coming LPNs and NA must hear report along w the RN. That way some delegation can begin immediately. Report begins promptly at 0645 and we really strive to end at 0715. Not too bad.
Man...That is interesting! Do your LP/VN's have assignments or are they delegated tasks to complete throughout the shift from the RN? Why does the RN give the report and not a LV/PN?
I'm a cna on a med-surg floor for 7 months, and am in school to be an RN in Spring 2004. I like the way they do report on my floor. At the beginning of shift, the charge RN writes the assignments on the board and indicates transplants and isolations. We all see each other and know who we're working with. During that 15 minutes I top off my fresh, on-board glucose levels for the next 5-6 hours by eating a meal. Thats really the key for a successful shift. I'm not DM either.
During the next 15 minutes I can talk to the departing RN's and gain additional PT info, neseccary for PT care.
I wouldn't go for any staff who tried to personally attack me during my arrival, glucose intake, shift orientation, clipboard preparation or actual PT debriefing.
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.
I used to have that problem until I said, "you're an intellegent nurse -- read it yourself." I also broke the habit by simply not using the flowsheet to give report -- I do it all off the top of my head. If I'm not reading, they're not reading. Of course, it takes some practice, but working flight and EMS got my brain working.
RN always, BSN, RN
151 Posts
What do I want to hear in report? I want to hear that the patient is going home! HA!