written up

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..

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

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.

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!

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.

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.

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.

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

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.

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.

not a lot of advice for you, except don't let them make you doubt that you a good person with a purpose and that you will find that. I don't know why nurses do this kind of crap to each other. We're supposed to be healers and supposed to be better than that. Makes me sad. This kind of crap has been going on a lot where I work and I've made it my mission to be kind to everyone and to write as many kudos and compliments as I can, trying to balance out the ugly with good. Try to be an agent for good, even as people target you. It will all be ok. :hug: