01.03 How to Give a Perfect Nursing Report (plus report sheet)
Providing a concise nursing report allows for greater continuity of care.
- Orders/Plan of care
- Patient’s bedside
- Patient input
- Patient questions
- Standard format
- Keep yourself organized
- Follow SBAR
- Who they are
- What is the problem?
- Why are they there?
- Code Status
- Abnormalities in assessment
- Recommendations for the plan of care
- Reminders about order due
- Documention must be placed in the chart that handoff has occurred
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
Providing a clear and concise nursing report is an art form that allows for greater continuity of care. In this lesson, we’re going to discuss a method for gathering and reporting on patient data in a uniform way that ensures clarity. When I was a brand new nurse, knowing exactly what to report on and then delivering that report clearly was incredibly hard. I wanted to share everything and as a result, would often come off disorganized. Luckily, my preceptor provided me with the nursing report sheet that helped me improve my report skills very quickly, we recommend using this report sheet which is attached to this lesson. Each time you give a report during your first year as a nurse. This is not a brain sheet or a sheet for you to work from during your shift, but rather a worksheet that should be filled out during the last half hour or so on shift as you prepare to provide a report to the oncoming nurse.
Now before you say this is too much work, you’re right, this does take a lot of work, but this method, insurers that you uncover exactly what you should say and report on in an extremely organized fashion. Give it a try and I’m confident that after two or three times of using it, you will absolutely swear by this method. All right, let’s dive in and let me show you how it works. Alright guys, here we are looking at our handoff report and assessment sheet. This is the sheet that I recommend that you print out about 30 minutes before the end of any shift and print out one for every patient. All right, and the reason we recommend this guys is because it provides you a very clear, very systems focused ability to write in everything that’s going on by system for every patient so that you don’t miss any theory that you don’t skip over anything.
The reason we use this versus like a nursing brain sheet is that the oncoming nurse does not need to know what you did on your shift or what was the patient looking like six hours ago. They need to know what the patient looks like now by everybody system so they can start getting a picture of it and go in and take care of the patient. They need to know the plan for this patient going forward. And again, the reason we recommend this is it forces you to think very clearly by every single major body system. It forces you to be organized and it forces you to gather the information that is needed to provide to your oncoming nurse. And again, we recommend this being filled out about 30 minutes to the end of your shift where there’s not a lot of options for changes to happen.
So this first area here, what we fill out here is we fill out the basic information of our patient name, age, allergies, code status, background, surgical history, etc. Then we fill out their providers who’s taking care of this patient. Then we begin to work down along here by every body system, neurological, cardiac, respiratory, gastrointestinal, genitourinary, skin pain. And then we explain the plan for the patient. And at the end we review orders, do skip protocol or stuff, skin check, neuro check, answer questions, and do some Foley care and basically just roll up all of our safety checks. Now this can be used as you prepare to give a report. This could also be used as your taking report so that if one big thing is missed, maybe they forgot to mention the orientation. You can say, Hey, I have an empty box here. What’s their current orientation?
You can also use this as you prepare to do an assessment on a patient. You walk into the room, you can pull this out and you say, what’s their orientation was their peoples with their extremities. Boom. Got my neuro assessment done. I can move on. So let me show you what you do. Basically, you pull up the sheet, you’d print it off, you would head over to the computer and you would start reviewing the patient’s chart up here. You’d write their name. Mrs. Jones is a 47-year-old female. Uh, no, no one drug allergies. Full code came in with the subdural hematoma background, found down by EMS past medical history. Maybe she had an MRI in 2007 past surgical history, no surgeries. The physicians or providers taking care of her is neurosurgery
so that the oncoming nurse knows who they can contact and call and who’s going to be the on call physician or provider for this patient. Now that we’ve gathered all that information and we can give a very clean, clear, succinct overview, that’s bar basically on this patient. Now we can go down by body system and we can say this is what you’re going to expect. This is what you’re going to see when you walk in there on this patient, and again, we do this last 30 minutes of the shift so that we could say the current status of this patient is, so we say our orientation AxO times four pupils are Perla
There are four extremities moves. All extremities follow, commands, speeches, clear behavior. They know where they are, they act appropriately. They have a sensation in all four extremities. And then we could put down here if they’re a stroke patient, their last NIH score and let the PA, the oncoming nurse know, you know, we have another NIH coming up in two hours. Okay. So nothing is forgotten here as we do this neurological report, then we move on to cardiac. We talk about their rate, the rate rhythm and their trends. You know, maybe their heart rates are one 20 and they’re an aphid. All right. And we noticed that we noticed they can go anywhere from 100 up to one 20. Um, and then we talk about their BP trends. And the reason we do this is we don’t want the nurse to walk in there and see this patient at one 60 over 90 and they get nervous because we’re telling them what their trends are.
You know, we’ve seen their trends anywhere in the one sixties over the 90s. So when they walk in there and they see it’s one 60 over 90 they’re not freaking out. But then we also say, Hey, we have this medication on, on a call for them. We have Metoprolol, 10 milligrams Q for PRN, right? And we talked about poults the strength of the poles and the cap refill. We talk about any Adima, right? This is a cardiac thing. This is our, our circulation. So we talk about it here. We say, are they out? Do they have STDs or Ted hoes? They have any VTE prophylaxis. Then a really important one. We talk about all the fluids and drips this patient’s receiving. Maybe they’re receiving 100 mils per hour of NS going through the right AC. All right? Then we talk about their temps. What’s their tips?
What are their trends? Ben, again, we’re again, we’re trying to get this really clear picture of exactly what to expect with this patient. Now we’ve done neuro, now we’ve done cardiac, now we can move on to respiratory. And I hope what you’re seeing is this is the way that you then give report. You just start here. Mrs. Jones is a 47-year-old female, no known drug allergies, full code subdural hematoma, um, found down by EMS. Am I in 2007? No. Past surgical history. Neurosurgery is taking care of her. Then you say this and you say neurologically she’s alert and oriented times four. Her pupils are Perla at four moves all extremities. She’s a full code or speech. Clear. Her buffet behavior is appropriate. She has sensations everywhere. We have an NIH do in two hours cardiac wise, she’s one 20 and a fib. She bounces anywhere from 100 to one 20 so you can see how awesome that report is.
Like how incredible is that report when all you’re doing is just reading all this data and all this information that you’ve gathered. So the next thing we want to move on to is his oxygen is respiratory. We’re going to talk about our oxygen delivery, how it’s being delivered and what methods we’ve seen there. What are their normal sets? How are their lung sounds? All right. Then we move on to gastrointestinal. What is their diet? Are they tolerating it well? Do they have residuals? So they’re on two feeds, a throne, mechanical, soft or whatever. This is where we kind of talk about all that. Then we talk about their last BM and the pattern. So last BM was, I don’t know when it was. A lot of times you’ll hear that, okay, was it two days ago, three days ago? When was this last BM or was it just the shift?
Then you can talk here about nausea and vomiting. A lot of your patients, especially your neurological patients will have some nausea and bombing. Now we talk about blood sugars and this is a great time to talk about the type of insulin they’re getting, how often they’re getting it, what their last blood sugars have been, and what we’re trying to see with a lot of these guys, we’re talking trends and we’re trying to give a nice picture of what the nurse can expect when they walk into that room. After we give them this report, they showed this clear image of who this patient is, so when they walk in there, they know what normal is, right? They wouldn’t know what normal is for this patient than genital urinary. How are they going to the bathroom? What does it like? All right, is it red? Is it orange?
You know, or is it clear urine and they’re going in the urinal, right? And they’re, they’re on dialysis. What does the schedule of dialysis? When is the next one? Then we move on to the integumentary system, right? We talk about any skin breakdown that we’ve noticed them gotta be very careful here because if we’ve seen anything, we want to report it here because we want to catch those skin issues as fast as we can. What are the status of surgical sites if they’ve had surgery, what does it look like in the perfect time to talk about dressings is right after that. No breakdown. We have a surgical site here. Here’s the type of dressing we’re using and here’s when it needs to be changed again. Now we can talk about pain. All right, so we’ve given our full assessment of this patient, right? Neurologically, the cardiac, respiratory, gastrointestinal, genital urinary integumentary.
Now pain, pain patients rating, their painting went from a four to a six. They have morphine available Q four hours, a two milligrams PRN last time they got it. See, we talk about last time. That’s really important when we’re talking about pain meds. Last dose received one hour ago, uh, patients rating their pain now at a four, which seems to be tolerable for them, but their rating anywhere up to an eight. See how incredible and concise and clear this report can be. Now really important. We talked about the plan for the patient. What are they going home when they plan to go home? Do they have any upcoming procedure? Patient has a CT scheduled at four in this morning. Um, here’s a couple of other PRN meds so that we have available. And one thing that I really always like to talk about is the family dynamics.
You know, and what does the family know, right? That’s one question I always, always ask when I’m getting report. And it’s something I like to share when I’m giving report that the family is aware that this is very serious. Uh, you know, Dr. Jones was in here and he mentioned that, uh, you know, that this is probably a terminal condition and the family’s aware of that and they’re making preparations, uh, for that for a nursing home or whatever. So you always like to say what the family knows cause you don’t want to be that nurse who blabs something that they weren’t aware of and that can be very hard to explain and stuff. Then you review orders, make sure you look at all the orders so they can see anything that’s come in. Uh, any changes to plan, review your skip protocol. Again, postsurgical stuff, do a skin check with the outgoing nurse.
Say, look, I already told you about the skin. Let’s go in. Let me show you that. Then do a neuro check. This is really important. This was massively important working in neuro ICU but can also be really important with your nonneuro patients just so they know that if there’s any neuro changes coming, see if there’s any questions. Then you do Foley care, you guys, it’s really simple as that. If you follow this process, you will have the most incredible reports and more importantly, we’re going to have a much higher continuity of care with our patients. So I invite you to start using this. Lastly, I wanted to share this quote that says, the ratio of We’s to I’s is the best indicator of the development of a team. Nursing is a team sport. Please be aware of that work as a team. We want this oncoming nurse to be very prepared to take care of the patient as we move on and with that guys, go out and be your best self today. And as always, happy nursing.