whats important in report?

[frustratedRN]

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?

[night owl]

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]

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!

[tonchitoRN]

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

[night owl]

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???"

[fiestynurse]

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]

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!

[Mijourney]

Hi. Everyone as usual, valid points. I agree with feistynurse, that if you have a well-organized and user friendly recording system, you don't need to drone on about a patient. As all of you aptly pointed out, the nurse needs to be able to give the substance of his/her patient care. More importantly, we need to continue to push for reduced nurse to patient ratios so that we can have the time to spend taking report on the small things that we may miss during our shifts that is so important to patient and their families.

I am resentful that we have to make a choice between getting down to the bone with report and getting the most appropriate (that does not mean every little thing) information for us to give our best care.

[JWaldron]

It depends; I always ask the oncoming RN if s/he is already familiar w/ the pts, and if so, give much less info, just changes and updates, current pertinent abnormal labs, new orders which are to be activated PRN (ie for temp elevations, chest pain, etc.) and not so much hx etc. If the RN is not familiar w/ the pt, I give more info, esp. about special equipment or procedures. This was much more of an issue when I did Med/Surg. I am now working on a RHB unit, and fewer pts. have uncommom meds or equipment, tho some of the SCI pts. do, and floats are less likely to be familiar with this stuff, so I give them a much more detailed report, and ask if they want or need info. Otherwise, I give a kind of barebones report and ask if there are questions. In the RHB unit, many of our pts are there for much longer, so we get to know them fairly well and 'spares' reports do fine, because we are all quite familiar with their needs and histories. New admissions need a longer report for the first few days.

Joan