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What's the best way to give shift report?

Posted

Specializes in Medical Oncology, Alzheimer/dementia. Has 15 years experience.

It's my last week of hospital orientation. My preceptor is there as a resource at this point. When I give report to the next nurse, my preceptor comes along. I report what the previous shift told me, what happened on my shift, any PRN's I gave, any procedures they have scheduled for the next shift, pertinent labs, plans for discharge. I think I'm giving a good report covering everything, then my preceptor will add this entire additional report. I feel it makes me look stupid.

So I asked her where do you get this extra stuff you tell the next nurse. She said "I forgot to mention this to you when I gave you report." and that she looks it up in the H&P. Why do I need to look up stuff in the H&P to pass onto the next shift when they can look up the H&P on their own? It would be like me looking up all the labs and reporting on them when I know the nurse will/should look them up herself. My preceptor said, "I just do it 'cuz it makes me look smarter."

My feedback about report has been good. When I ask the oncoming nurse if there's any questions, they say no. In a week I'll be giving report on my own without a preceptor at my side.

Its a funny thing, the way some nurses want this big history in report ( when they can clearly read the chart) and others just want a shift report, some write pages of report and some nurses dont write anything. You just always want to be thorough and give only the most pertinent info. I give my report in a specific way each time, and during my shift i at least try to read the er report on the chart and maybe an HP. ALOT of the time, the info you get from the last shift is wrong, and i think you look stupid saying wrong info and then saying "well thats what i got in report" I think to give a good report you need the admitting dx, brief history of how they got there, how and with what they were treated in the er, and then ill do a review of systems, neuro, cardiac etc etc. Then iv sites, fluids, pain meds, any riders, any tests that day, any pending labs to look for, and finally any social info, ex= family situation etc. It may seem like alot but when you have it down it just rolls off your tongue. And if you dont know, say i dont know., there are also alot of sample report sheets on the web, i downloaded about 10 lol, all a little different with format, whatever works for you. Hope this helps.

Tracey- critical nurse 17yrs.

Tait, MSN, RN

Specializes in Acute Care Cardiac, Education, Prof Practice. Has 14 years experience.

I think perhaps she was being flippant when she said "it makes me look smarter". I know that I often read the H&P and if there was anything particularly pertinent (hx of depression etc) I will mention it so the oncoming nurse has a heads up.

It is important to note things from the H&P to some extent, because sometimes the oncoming nurse may not have time to pick up the chart for awhile and get a broader picture of the patient.

Another thing that might be going on is that your preceptor is someone who likes to cross every T and dot every I, so despite your report getting all the necessities across, she feels it is important to add a few more facts based on her history and experience. Or she may just want to make it known that, despite you caring for the patient, she is also aware of the full picture It may be her way of showing to the oncoming nurse that she is being an attentive and effective preceptor.

I wouldn't take it personally. If you are getting good feedback, then continue your reports as they are, ask for feedback in a week or two of doing them on your own, and then think again about some of the extra information your preceptor was giving.

Tait

I use SBAR to give report....it's never fails!

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Pangea Reunited, ASN, RN

Has 6 years experience.

Your preceptor has time to look these things up because you're about ready to be pushed out of the nest and are doing most (or all) of the work. This is a good sign.

My absolute favorite way to give report ever was a hybrid method where you gave the bulk of your report at the nursing station but then as you were leaving you walked into the room with the on-coming nurse to introduce the new nurse to the patient and go over anything that was hard to explain without visuals, also gives you a chance to do a quick look at the patient and iv and make sure you didn't forget anything.