What to write down when getting report

March 30, 2018

One of my biggest fears in the real world of nursing was giving shift report. Recieving report is simple...just listen and take note (of what is important). But giving report is like the ultimate nursing task that takes for ever to actually achieve and no one teaches you how.

(I'll be sharing my secrets later)

My nursing school did not initially let us sit in on report. It was a missed opportunity to learn more information about my patient and what happened in the last twelve hours. 

Report is given in a number of events: when one nurse is handing off the patient to the next shift, when the doctor is rounding, or when your patient is transferring.

Shift report is a great time for nursing students to learn key information about their patient that they missed during chart checks. I cannot stress enough, to wait to ask questions until report is done! Nurses will get frustrated. If you do not know something, jot it down and ask your nurse after getting your patient settled. Be respectful of his/her time and wait for your opportunity. They have graciously allowed you to tag along in their workflow and you do not want to slow them down, they will appreciate you so much more!  

When getting report make sure to take note of

  • Name/ Attending MD/ Code Status
  • Allergies/ Precautions
  • Main Diagnosis: Why are they there?
  • History that applies to the admission. For example, if your patient is admitted with pneumonia, it is useful to know that they are also a long time smoker. I do not need to know that they had a broken arm 2 years ago. It does not relate to the current admission.
  • Your assessment. This is not a complete head to toe. Just mention abnormal. For example, crackles in the lower left lobe. Not that lung sounds are clear.
  • Any tubes/lines/drains
  • Any test/procedures that they might be leaving the floor for and any that they have already had
  • and the plan of care. What are the goals for discharge? Why are they still here?
Before leaving the room, be sure to ask the patient if they need to use the restroom, if they have any questions, and that all their possessions are within reach. 

My hospital participates in bedside report. Prior to discussing your patient's information, remember to ask family members, friends, or individuals in the room to please exit. Patients do have the right to request that their love ones stay in the room.

Hope this helps! I will be sharing in the next post some tips on actually giving report. 

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