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whats important in report?

Posted

just asking other nurses what they think is improtant information to pass on in report...

i like to know:

diagnosis

orientation

any events thru the last shift

prn med times

accuchecks.

anything out of the norm (abnormal labs)

location and description of wounds--wound care

sometimes report takes long because the nurse giving it tells every little detail.

i dont write down all that much.

i dont write down vitals unless they are abnormal...same with labs. i dont care how many rbc a patient has unless its dealing with h and h

they dont have to tell me how old the patient is or who his doctor is,....thats all written on our care papers. so is past medical history.

is there a general protocol for report?

am i missing the boat here?

I agree with you. We have PCAR (patient care activity reports) though that are printed out at the beginning of shift that has age, MD, admitting Dx. So you don't need to tell me that. It doesn't have past med Hx so I like to hear it. Including all that you said I like to hear parameters: call MD if ....., Give clonidine if BP >.....and so on, also any lines (permacath, tessio) or HD grafts.

I'm unaware of a protol, but one would be time saving. Sounds like you would give a fine report........Your on the boat!!! :D

hoolahan, ASN, RN

Specializes in Home Health.

Agree with everyone. One nurse I used to work with called that kind of report all meat and no gravy! I liked that one.

One more thing I like to know as an ICU nurse is a bit about the family. What have they been told about the pt's condition? Do they know the path report is + cancer? Are they supportive? Are they ready to discuss DNR if appropo. Just a little psychsocial, what is the pt's biggest fears, etc... That's the stuff many people pass on but don't document. In other words, prepare me if the family is nuts! :D

the family is always important.

i always ask about them when im told that a patients condition is grave. i also ask if the patient is aware of their condition.

i report off to one nurse that writes down everything i say. when she reports off she tells me every little thing. i know before i even go in that ill be there for about 45 minutes.

report shouldnt take that long. it puts me behind right at the begining.

hoolahan, ASN, RN

Specializes in Home Health.

frustrated I have had many reports like that, where I wanted to grab a pillow and start dozing it was so montonous and boring!

What you have to do is say, "Yes, I remember, I had these pt's yesterday, just tell me the highlights of what happened today." If they keep rambling, cut her off, and ask the questions you need to know, keep firing questions, get what you want, them flip the kardex to the next page and do the same. After a few reports like this, she will (hopefully) get it. OR, more to the point, you could tell her privately that you would like if she could shorten her report a bit, because you have to start your assessments promptly or you feel you are behind all day.

we have one nurse who goes on and on in report. she'll say "i got the pt. up to the bathroom and the pt. said she didn't feel well so i took her blood pressure which was 120 over 80 and i helped her back to bed. then i asked her if she was having pain and she said yes but not much. so then she said she felt ok and asked me for a blanket. i got her the blanket and covered her and left the room. she rang again but said it was an accident." talk about a waste of time. she charts the same kind of stuff. he said she said alot.

CEN35

Specializes in ER, PACU, OR.

ER to floor...........

Name

age

allergies

Hx

events up to situation...

Pt baseline

relevent meds to situation

relevent labs to situation + abnormal lab values

Radiology issues if relevent

EKG

IV's -drips.sq start or ours

last set of VS

then ask any questions?

:)

me

I will not read thw whole chart they can read I assume?:confused:

me:D

I work in an IMCU unit so:

PMH unless I had the patient the day before

VS if unstable

gtts- rates and next labs for those if needed

orientation

dressing changes if needed- be it Picc or wound

sxn needed previous shift

any tubes in any orifices or elsewhere

Code Status

family issues and needs

lines pulled- time, off bedrest when, site assess, lab times

Pertinent stuff for Vents, bypass, or recent ABGs

Otherwise I can gather from flow sheets and chart.

I have found certain nurses want every single detail and some that don't even want to listen to tape and for you to give them a verbal highlight.

I am probably more thorough when they transfer to another unit, more stable floor and I try to listen to what they want.

I still keep trying to adjust and understand the ER's report

Explain to me CEN35. I can't tell you how many times we have gotten patients that come in with chest pain and the nitro gtt is set up at 5 mcg and they hit the floor and still having chest pain and pressure is up and they haven't turned the gtt up and or in CHF and haven't listened to their lungs Please explain if I am missing something here. I have backed off from needing a thorough report and hit me with the highlights but geez!!!

CEN35

Specializes in ER, PACU, OR.

Sorry Cafe...........

If they still ahve chest pain they either have an SBP of about 110 and the NTG drip is maxed out, and/or they are also on heparin and either Riapro or Integrelin, and the trip over is temporary until the cardiologist is present to cath him. Also, they have had enough Lopressor to keep their heart rate at about 60, and they are on O2, what else is there? Myabe their EKG looks perfectly normal also? Maybe it's GI!!!! LOL! Sounds like lame transfers, from lame staff in your er........of course thats just my opinion.

me:)

I used to work on a busy Telemetry unit where it was not uncommon to see 8-10 patients on an 8 hour shift. I used to laugh when I gave report to an ICU/CCU floater. They wanted every detail including PMHx and ALL labs. I used to tell them that info. is in the chart. When one nurse got indignant I explained "look you will be lucky if you spend more than 15 minutes with that patient. It is not important if that patient had a tonsilectomy at 6 yo. What is important is XYZ." This same nurse complained if when you gave the dx of MI you did not say where the MI was. I thought maybe she had a point so I asked her "on Telemetry is the care different for a lateral wall MI or an inferior wall MI?" She had no answer and never asked that question again. :cool:

MollyJ

Has 36 years experience.

Tonchito,

Alot of acute CCU nurses will want the location of the MI because it warns you of possible complications (ie MI area specific blocks) and may dictate treatments (RV MI). HOWEVER alot of these problems become less likely in the post-acute phase (which is why you don't care about them).

I have been an ICU nurse that floated to a lesser acuity unit and it is hard to "turn down" your need for information. Knowing those kind of details in the ICU can help you anticipate and respond to complications. Knowing them on a more general unit has a lower "yield" of usefulness and can cause sensory overload. Most ICU nurses feel pretty out of control on lower acuity units because they CANNOT amass the type of detail they often can in the ICU.

I agree with the "just the facts, ma'am" lists that have been posted here, but I also like to know about family coping issues, DNR issues but not in excruciating detail.

CEN35--- Thanks. We are (or there is a comittee) working with the ER on some of those issues- like Nitro Gtts. I figure other problems can be worked out and sometimes escalate due to the fact that nowadays our unit is generally full, or we triage out and are near capacity on the next shift or within two shifts, which at some point delays things in the ER and causes backup down there. The other is diversions from our UW Hospital. They have serious staff problems so have to divert. They also haven't settled their contract and the hospital won't negotiate anymore and has just put into effect their offer in hopes of breaking their union. Doesn't solve any of the problems though and they still can't retain staff. Causes alot of open beds not utilized and our hospital and another are full due to their overflow!! Can get kind of tense at times!!

I only like the highlights because giving report on 30 pts can be a bit lengthy. Then again, there are nights when everyone slept, a very uneventful night and feel that I should have SOMETHING to report. I should be thankful for those nights which are few and far between...

SharonH, RN

Specializes in Med/Surg, Geriatrics. Has 20 years experience.

Originally posted by tiger

we have one nurse who goes on and on in report. she'll say "i got the pt. up to the bathroom and the pt. said she didn't feel well so i took her blood pressure which was 120 over 80 and i helped her back to bed. then i asked her if she was having pain and she said yes but not much. so then she said she felt ok and asked me for a blanket. i got her the blanket and covered her and left the room. she rang again but said it was an accident." talk about a waste of time. she charts the same kind of stuff. he said she said alot.

Boy do I feel your pain. I work with a nurse like that. She wants to tell what time she hung her meds, the fight she had with pharmacy to get the meds, the argument she had with the patient to get out of bed. I don't need all that INFO. She and several of my coworkers are guilty of this in fact. I have asked her many times to please give me the highlights and move on but to no avail. I hate lomg-winded reports. I have even mentioned this to my clinical manager with no results.

On the flip side are those nurses who want to know each and every detail whether pertinent or not. He has a peripheral IV, does it matter if it's in the right or the left? Presumably you'll find that type of info out when you do your assessment. I can't remember whether or not he's on antibiotics or what kind they are, you'll have to find out when you check the MAR. That's the height of laziness!

mollyj - thanx for the info. now i feel better informed. :cool:

I work with a nurse who starts off everytime with, "We have 57 warm, breathing bodies!" One time after receiving one of her reports, found one, slightly cool body with no pulse, no resps, no nothing! She LIED!!! So when she says we have x# of warm, breathing bodies, I always say, "Are you sure???"

To give a good report, I think it's important to have a well organized, up to date kardex. Most reports can be tape recorded, with the off going nurse being available for questions afterwards. Sometimes it can be very annoying, when you are trying to get through report and people start going off on discussions about patients. Especially, if you are just coming off a night shift and you just want to give report and get home. Save those little patient care conferences for later.

Mother/Infant unit Report:

MOTHER:

Room,name,age, Obstetrician

Spanish speaking?

Gravida/Para

Blood type/Rhogam needed?

Significant prenatal history

Delivery type/date/time

Tubal lig done?

Significant labor/delivery info

Blood loss/H&H

Type of anesthesia

Gestational diabetic? Accuchecks needed?

Pre-eclamptic? MgSo4? Refelexes? Clonus?

VS

Fundus/lochia

Diet

Voiding? I&O

Episiotomy/C-sect incision

Ambulatory

Significant psycho-social info

IV rate/ how much left in bag?(nothing bugs me more than a dry IV bag when you get out of report)

IVPB/antibiotics?

pain/meds given and is it effective?

Does she plan on going home today?

Where is she at with discharge teaching?

INFANT:

Sex/Pediatrician

Weight

Gestation

Pooping? Peeing?

VS

Breast feeding/any problems?

Formula feeding

Bonding

Significant birth problems/traumas to baby

Circumcision planned?

Chem BGs needed?

hoolahan, ASN, RN

Specializes in Home Health.

Wild, if someone wants me to read the chart, I just smile and say, you don't want me to repeat all that, you can read it yourself in the chart, right? Let me just give you the highlights of what happened today. Wean then off by letting them ask you if there are any questions? If they ask something that can be found on the chart, you can a) tell them it's on the chart/kardex, or b) open to the spot the info is on the chart/kardex, and say, that is right here on the chart, see? After awhile they will get the hint.

What used to drive me out of my tree is this one nurse who was always late! The kicker is, she lived in a residence on the hospital campus. She had very long hair, always came in with it wet, which is fine, but one day I finally had it and I said to her, L, do you realize that 3 pm is when you are supposed to be here? Not the time you get into the shower? I said it in a joking way. Then I told her I was enforcing a new policy. If you showed up at 3:15, you get a 15 min report, if you show up at 3:20, a 10 min report, and 3:25 (her typical arrival time) you get a 5 minute report. Guess what? She was never more than 5 minutes late again!

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