What are your most important pieces of information when giving/getting report?

rollingstone · Aug 10, 2003

-Chief complaint

-Diagnosis

-What was done to make chief complaint better.

-Meds given or held, IV's, allergies.

-Pertinent labs and history.

-VS, assessment findings.

-Mental status; code status.

-Family members present.

grouchy · Aug 10, 2003

I definitely try to follow a system, so I don't miss anything.

1. Name, age, gender, physician, code status, allergies, contact precautions

2. Reason for and date of admission, and date of surgery (ie 3 days postop)

3. Medical history

4. Now that I've worked in ICU, I still visualize our ICU flow sheet and go system by system so I don't miss anything. Sometimes, I'll start with a one-sentence recap of the most imp problem , then start the systems review, and expand on the most imp stuff when I get to that system. I find I'm less likely to forget to tell people things that way. If they don't like it, tough!

5. I always try to write notes on the report sheet and verbally indicate any upcoming timed tasks - ie. blood sugars, nonroutine labs.

6. Also good: Did you bathe em? We write it on a board, but sometimes people forget!

7. As a newbie, just get used to the fact that people will always criticize your reports. Too much, too little, whatever. Many of the concrete, specific criticisms I've received, usually of the "Why didn't you do X,Y,Z in response to pt's problem during your shift?" have been an important learning tool. It always humbles me, but it's how I learn, so I don't mind it. On the other hand, I've learned to just ignore the "you're too wordy" type of thing.

nowplayingEDRN · Aug 10, 2003

-age and dx

-code status

-pertinent med hx/allergies

-VS and frequency

-CV/rhythm

-Resp/o2

-GI

-GU/foley

-labs/cardiac enzymes/pending results

-diet/activity

-lines

-I/O status

-treatments/interventions

-surgical incisions/dressings/drains

-pain scale

-medications

-family present

-pt teaching

-discharge planning

nurse51rn · Aug 10, 2003

Ditto to all. Plus: monitor status. Rhythm, intervals, any runs of VT or SVT. Hep gtts and APTT; when is the next due? Consults and testing to be done (or done this day).

debralynn · Aug 11, 2003

As a tech(still!) these are important things they will need to know!

Turns

Diapers/Foley (also if pt has had constip or diarrhea that nite)

Also if any breakdown of bottom has occured

Vitals/q4 or q8

Diet/ and what restrictions

Code Status

NPO

If they have had any hip or knee surgeries

elevation of bed

O2

if patient is expected to die any moment(this is always helpful)

Fall alert/ also how many assist pt needs to BSC

restraints

heel boots

Isolation status

I know this sounds like a lot, but as a tech I float. So I might work on a different floor every weekend nite I work.

Also one other thing:

Please don't talk 90 miles an hour when giving report, we might miss something really important!

live4today, RN · Aug 11, 2003

All I really want to know is how much BS am I going to be in for on my WATCH! :rotfl:

Are they full codes or no codes.

When did they receive their last pain med.

How much IVF is up in the bag and the name of the IVF hanging/ordered. (not always the same ya know) :rolleyes:

Any test procedures I need to know about, stat labs, abnormal vital signs, discharged to home or restraints in use for being combative.

I can read for myself their name, age, diagnosis, doctor, admit date, and other stats. Don't repeat the same thing over and over. Get to the point, and have a goodnight! :rotfl:

Speaking of "Goodnight?" Out of here til tomorrow. No pep in my step left right now. Just finished two twelve plus hour shifts in a row.

kimmicoobug · Aug 11, 2003

I am a new nurse, and my reports tend to be a bit lengthy. It also depends on what type of patient it is and what unit I am on.

On med-surg, I would give this info in my report.

1. name, room number, sex, diagnosis, and MD.

2. go through a quick systems check, focusing more on what systems are a priority for the particular patient.

3. any abnl labs or labs ordered that day or the next day.

4. I mention pain, anxiety, and how much and how often I medicated for it. If I did something non-pharmaceutical, I mention that.

5. I mention any new orders (I take in a copy of the order as I tape and read them off).

6. If diabetic, the blood sugars and how much insulin I gave.

7. Any other abnls or anything out of the ordinary that I feel is important.

Ok, well it doesn't sound lengthy, but my report seems long when I give it. If it is a patient that I know the staff is familiar with (EX. We have one girl in OB post hyst who has been there for two weeks. Everyone knows her and why she is there, so I didn't mention her dx last night to the night shift because those two nurses were just as familiar with her as I am).

One thing I have found that would be very helpful in the OB department that I am currently picking up shifts at is if they would mention what kind of diet the surg patients are on. This is the only unit in the hospital that does not use a Kardex system. I usually have to shift through pages of doctor's orders to find out. My one patient that has been there for two weeks had surgery again on Thursday. On Saturday, she was still on a full liq diet and I had no clue. Usually, they are on a general diet by the following evening. That would have been good to know in report.

l.rae · Aug 11, 2003

my pet peeve in giving report is the nurse that frequently interrupts asking non-pertinent questions. If the pt is being admitted for cellulitis, do not ask me about his breath sounds. Can we say focused assessment? ER nurse here too.

redwinggirlie · Aug 12, 2003

This is fantastic, everyone! Thanks.... Again, more! More!

Louie18 · Aug 12, 2003

Are vitals and how much care they require.

Louie18 · Aug 12, 2003

Diagnosis being a given.

redwinggirlie · Aug 13, 2003

Good point about talking ninety miles an hour. I've heard some reports that were wayyy too fast. We all missed important stuff. Thanks again everyone.