In this podcast we talk about giving a succinct, flawless and informative end-of-shift report. Sounds simple enough, right? It should be, but you’d be surprised how often a bad shift report can leave you with more questions than answers. But, if you follow these guidelines, you’ll be someone that all the other nurses LOVE getting report from…and yes, you will be giving report as students, too!
An awesome shift report starts with your “brain sheet.” This is a sheet of paper where you write down all the pertinent data you need to take excellent care of your patients. Here’s what my brain sheet for the ICU looks like:
Note that you would never use a brain sheet like this for Med/Surg or someplace where you have 4-5 patients…you’d never get through report before the end of your shift!
As you give report, you basically go through all the items on your brain sheet. I like to start with the patient’s name, age, admit date, diagnosis, who the docs are, allergies, code status and any pertinent psychosocial stuff. It might sound like this:
This is Jane McDoe, 46 year old female. Admitted on March 10th for a perforated diverticulum. Surgeon is Dr. Hodges, renal is consulting. She’s allergic to penicillin and is a Full Code. Her daughter is Gertrude, but she lives in New Zealand and won’t be here until tomorrow night.
Next, you want to get into their pertinent past medical history and why they came into the hospital. It might go like so:
She has a past medical history of chronic renal insufficiency, diverticulitis, DM2, HTN, smoker with 20 pack-year history and bipolar disorder. She presented to the ED with severe abdominal pain and lethargy.
Now, you want to go through a brief story of what’s happened to the patient since admission. Again, you’d only go into detail if the patient is in the critical care setting. If on a Med/Surg floor or something similar, just the highlights…surgery date or other significant milestones.
She got a CT of the abdomen, was admitted and had surgery with Dr. Hodges that same day. She was hypertensive after surgery and unable to wean off vent. She came to ICU, stayed intubated overnight and self-extubated on the morning of the 11th. She was emergency reintubated and remained hypertensive…now on a Cardene gtt. Chem panel showed hyperkalemia and hyperphosphatemia in conjunction with minimal urine output and an increasing creatinine. Renal consulted and decided to start dialysis…a Quentin cath was placed and HD started.
Once you’re through your little snapshot of their hospital stay and significant events up to that point, you start your head-to-toe. Pain, temp, neuro, cardiac, respiratory, etc… You end with your recommendations and the plan for the patient. I like to include any upcoming lab draws or scheduled tasks so they don’t get missed. And because you wrote everything down on your brain sheet, you won’t forget a thing. Easy peasy!
Take a listen and see just how flawless and simple end-of-shift report can be.
What makes YOU nervous about clinicals (if you’re a student) or your new role as an RN? Let us know in the comments below!
P.S. You can download those amazing brain sheets here!