What is included in Report?

CoffeeRTC, BSN, RN · Jan 28, 2006

At the end I may give a heads up on any other issues...like family in room and very demanding...those type of things.

RN34TX · Jan 28, 2006

One of my favorite topics from my med/surg days.

My #1 pet peeve was nurses either feeling the need to tell me or expecting me to tell them (depending on who's relieving who) each and every last event, on a play by play basis of the patient's last 12 hours, particularly lab values.

My simple rule here is this: If I didn't need to call the MD to get further orders or do anything outside of ordinary interventions, it does not need to be discussed in detail in report. That's how report ends up taking 30+ minutes and it shouldn't take that long to discuss 6 patients that had no major events over one shift.

Blood sugars for example. Some nurses obsess about them and I've often had night nurses looking for "trends" and want me to tell them what the patients blood sugar was before every meal that day.

I say that unless I had to call the MD and get orders because their sugar was off the sliding scale or if I had to push an amp of D50, it is a waste of time to sit and discuss a patients blood sugar every time it was taken over the past 12 hours.

"At noon, her blood sugar was 265 so I gave her 4 units of regular per sliding scale." No need for that.

In addition, this is all info that the relieving nurse could look up long after I clock out and go home if they are so interested in it.

I would often get this type of long detailed report while other things got left out like whether or not they have problematic family members in the room all of the time giving the staff a hard time, new lines or tubes that still needed to be x-ray'd and cleared for use, new orders that never got initiated for one reason or another, or procedures that were scheduled for the day.

Now those things are helpful to the nurse that will be relieving you yet are often the most left out items in report.

Lorie P. · Jan 28, 2006

i give my report the same way each time and it goes something like this;

i start with my report sheet that list pt, age, doc, dx and any other docs as consults

then i start with code status

abc; 02 if any

ivf or psl

diet

blood sugar if ac/hs or q 6 whatever is orderd and only the last bs reading and units of insulin i gave

then any abnormal labs

telemetry readings

and then any other info such as mrsa, hiv that type stuff one needs to know and any prn pain meds or n/v meds

and they are very demanding

this way i make sure to include the "important stuff" i could care less about each and every bs reading if they ate or drank all the meals or po fluids

hope this helps.

HeatherLPN · Jan 28, 2006

I also let them know about any dressing changes, suicide precautions, or extreme behaviors.

RN34TX · Jan 28, 2006

i give my report the same way each time and it goes something like this;
i start with my report sheet that list pt, age, doc, dx and any other docs as consults
then i start with code status
abc; 02 if any
ivf or psl
diet
blood sugar if ac/hs or q 6 whatever is orderd and only the last bs reading and units of insulin i gave
then any abnormal labs
telemetry readings
and then any other info such as mrsa, hiv that type stuff one needs to know and any prn pain meds or n/v meds
and they are very demanding
this way i make sure to include the "important stuff" i could care less about each and every bs reading if they ate or drank all the meals or po fluids
hope this helps.

yes, isolation status (mrsa, vre, etc.) is another one that people have often left out in report to me.

but they never forget to tell me that they drank all of their can of ensure today. lol!

Lorie P. · Jan 28, 2006

or that they forgot to tell ya pt was npo and found out later that someone gave them something to eat to drink!!!!!!!!

i also include if they are npo or not and it they are going for any procedure and it the consents are signed and a big pet peeve of mine they don't tell ya is if a pt is receiving blood and you find out when doing your assessments!!

but yet they tell me that so & so likes or prefers oj over apple juice!!

jimthorp · Jan 28, 2006

I work LTC/Rehab and give report by exception, except for new admits.

VickyRN, MSN, DNP, RN · Feb 7, 2006

I have attached an excellent guide for giving report: Situation Background Assessment Recommendation (SBAR). Hope this helps :)

DONN · Feb 7, 2006

In our place they will string you up from the iv pole if you DONT give a fully detailed report including all the things that RN34TX stated. I know its redundant sometimes but that is just the way it is where I work, Additionally you should also note and describe in detail: incisions, fluid color/composition from drains or NGT, if pt. has a Pegg then note bumper depth, where there IV lock is and the date on same, .....I could go on and on

RN34TX · Feb 8, 2006

In our place they will string you up from the iv pole if you DONT give a fully detailed report including all the things that RN34TX stated. I know its redundant sometimes but that is just the way it is where I work, Additionally you should also note and describe in detail: incisions, fluid color/composition from drains or NGT, if pt. has a Pegg then note bumper depth, where there IV lock is and the date on same, .....I could go on and on

I'm sure you could and I'm sure that your unit goes on and on in report as well.

There comes a point where I'm often wondering if I'm giving a "detailed" report in order to save my relief from having to actually do a real assessment on their patients.

Something to think about.

It's just that years of experience has taught me that some of the most by-the-book and difficult nurses are the ones who get mad simply because you leave them anything more than the bare minimum for them to do during their shift but they disguise it as being thorough in their work.

The reality is that they just want you to be thorough in your work to the point of them not having to do much else during their own shift.

I once had a nurse call me in a panic because she had a night from hell, reported off to her relief for her other 5 patients, then realizing on her way home that I was assigned her 6th patient but she never gave me report.

Well guess what?

I wasn't in any sort of panic about it and certainly wasn't going to report it to anyone.

Why?

Because I'm a nurse, and I can walk into a patients room and see that they have a foley, an IV and what date is written on it, their post-op dressing and what it looks like, assess their lungs, level of orientation, bowel sounds, etc. the rest I could get off the kardex and whatever means to find out about the patient. The MAR told me even more about the patient. They had a sliding scale, so I knew to check glucose levels, BP meds, you get the picture.

Yes, report is important.

But it wouldn't totally cripple me as a nurse if for some reason I didn't get it, and if it does cripple others when they don't get some detailed "full" report on all of their patients every day, then maybe they need to examine their own nursing knowledge and skills because report is not supposed to be a full assessment of the patient to the point where you just copy what the previous shift observed and assessed.

We're supposed to be professionals, not peanut heads to merely be given instructions and follow them without question or deviation.