written up

[Ms.RN]

I've worked in the hospital a little over 3 month now. Previously my nurse manager told me that nurses are complaining that I am not giving a good report. Then yesterday she wrote me up for not giving a detailed and accurate report. She said I am suppose to be giving a head to toe report to the next shift. I told her that when I was orientating with preceptor she didnt show me to give head to toe report but only pertinent informaiton and that's how other nurses are giving reports. Now i'm fearing that i'm about to be terminated from my job. I feel like my nurse manager have made a decision and its going to be only a matter of time before she terminate me. If she write me up one more time then I'm out right? with only 3 month of working I am not going to be able to find another job. Should I start looking for other job?

[SuperStarRN]

I agree that you should have her be present one morning when you are giving report so that she can see for herself and not write you up for something someone told her. If she wants to fire you she will. If you like the job then try to work it out. If she continues to write you up or complain that you're not doing a good job then I would start looking for a new job because she might be looking for excuses and starting her paper trail to fire you anyway. You need to do some serious pondering.

[StrwbryblndRN]

I hope all the previous posts help.

I am a little concerned that you got written up. Without hearing for themselves your report it is hard to fathom that the manager wrote you up because of someones perception. Especially a new nurse. I would think that they would help you, instead of hurt you in your new job..

[TriciaJ, RN]

According to your post, you were spoken to previously and then again by your manager. The best way to deal with criticism (whether fair or unfair) is to ask for more information. What's missing from your reports that's causing a problem for the oncoming nurse?

As a new grad, it looks really good if you solicit feedback and act on it. Show them you're serious about doing a good job; don't bother pointing out what others are doing. Good luck to you.

[tcvnurse, BSN, RN]

Nerdtonurse, that is exactly how we give report at my hospital. Apparently, we really want to know everything! lol

[Creamsoda, ASN, RN]

Am I the odd one out. I give a head to to report. It doesnt take anymore time and then im sure ive passed along all the info and nothing is missed. I think its poor practise to do otherwise. In the ER yes, obviously its just pertinent systems but in med surg, tele, ICU all things need to be covered. To the OP, create your own cheat sheet that you can work off through out the day that includes all systems, labs, IV, meds ect so that when you report off just go Head to toe and you wont miss anything. If the oncoming nurse tells you your talking too much just say you want to give a thorough report.

[PediNurse3]

I didn't really give a good report until I went to work in the PICU. I got to the point where I could give a report that included the following in about 5 minutes

- Name

-Age

-ICU day

-Vent day

-Post op day

-History

-Diagnosis

-Changes and events over the past 12 hours

-Airway (ETT size, placement, vent settings, nasal canula, room air, etc), A(C,V) BG values

-Breathing (Sats, sat goal, breath sounds, last chest xray respiratory meds)

-Circulation (HR, BP, meds)

-Neuro (pain, sedation , LOC, meds)

-Electrolytes

-Gastro (abdomen, last BM, meds, bowel sounds)

-Hematology

-Intake/output

-Infection (isolation, WBC's, antibiotics)

-Joints and skin

-Lines

-Nutrition (kcal/kg/day, NPO, feeds, bottle, diet)

-Other/plan

-Parents/family

That's the bulk of it. I'm positive that there's more but I haven't given report in awhile. :) Once I got it down, it was a breeze!

[Been there,done that, ASN, RN]

I suspect report is not really the issue, there is something going on that irritates SOMEBODY and report is the only thing they can get you on.

Talk to somebody you 100% trust and ask what that may be.

Give a head to toe...abbreviated of course.

Patient is alert, oriented, lethargic...brief description of mental status.

ambulatory status

Heart RRR, Telemetry...

Lung sounds, O2 , cough , SOB...

abdomen soft, + b.s. , no BM x 3 days

GI/GU status

Presence/ absence of edema and peripheral pulses

skin issues/pain issues

psycho/social problems

Abnormal labs/ test results

Anything ordered ..but not done . That is plenty for any report, takes minutes.. prepare b4 shift change.

[SuperStarRN]

I suspect report is not really the issue, there is something going on that irritates SOMEBODY and report is the only thing they can get you on.

Talk to somebody you 100% trust and ask what that may be.

I totally 100% agree with this. It has nothing to do with your report. You should pay close attention to your co-workers because I know from personal experience that the main ones that laugh and talk to you everyday will be the first ones to throw you under the bus. Not everyone is like that but some are.

[MsBlissful]

I'd sit down and ask them to help you write a report from. One to use as a tool to remember report. It will come second nature sooner or later. To be written up for this is lame, but welcome to acute care.

They love to write up people for things left and right. Use caution.

[Ms.RN]

Thank you everybody. I have this gut feeling that she wants to get rid of me. I cant find other job at this point becuase i've worked only 3 month at the hospital and I dont think i can transfer because of my wirte up. I dont really have anybody at work who i can talk to and thats probably why i cant sleep at night

[hope3456, ASN, RN]

Ms.RN - I was in your shoes a couple years ago. I know how you feel. Unfortunately your story is all to common in the nursing field. I'm not working acute care right now but don't most units use a standard report form? It sounds like you are in a toxic work environment...start the job search. Something better will turn up when you least expect it.

[Flo., BSN, RN]

We have a standard report sheet that includes the full head to toe. It was implemented a few years ago and I think it was the best thing that ever happened to my floor. Maybe you could suggest the same for your floor.