Originally published at http://onlinelpntorn.org/2014/how-to-give-a-good-report/ on 11/14/2015
The ability to give a good patient report is not only a skill that will earn you respect from your colleagues, but also may save patients from serious errors caused by poor communication. As a practicing nurse, you will regularly be called on to give report on patients. The most common scenario is intershift report, a time-honored source of systems-level errors. But in addition, you will have to give report to physicians in varied circumstances, to nurses at other facilities, and, if things have gone badly, to the people coding your patient.
Intershift report skills should be developed posthaste because any time you care for patients you will be on both ends of it. Many nurses have their own forms to organize information that they carry with them, at least initially. I had one when I was new, and I am a huge believer in checklist-type forms. Everyone forgets something sometimes. Having a form both prevents you from leaving something critical out when you hand off your patient and from asking about critical things before the off-going nurse is gone. It keeps information from getting lost.
The information you give in your shift report depends on your specialty. A public health nurse will have a hugely different report than will a neuro ICU nurse. Typically, though, things to mention will include why the patient is a patient (what went wrong?), drug allergies, significant medical and surgical history, assessment findings, and things to follow up on.
"Things to follow up on" is the scary place where stuff gets missed. In inpatient situations I made a point of not only asking the off-going nurse if there was anything in progress that needed to be dogged and also asking the patient if she knew of anything. It was part of my "hi my name is Megen I'll be the RN coordinating your care this evening..." spiel ("OK, the game plan is [blah blah]. I'll be following up on [blah blah]. Anything else you're aware of or need to add?").
I know nurses are hovering over the "back" arrow right now, but bear with me. I know it seems as if that's asking for trouble, but try it! The patient will feel as if she's on your radar and will be on the call light less.
As far as other reports (to physicians when you call for an order, to a nurse at a receiving facility, to a code team...), you have varying abilities to prepare. Calling physicians for orders is easiest because you're the one making the call. There is no excuse for not having current vital signs, labs, medications, and so on at the ready. This is where the SBAR (situation, background, current assessment, recommendation) format is very handy.
The unexpected "they're on the phone for report" for someone you didn't know was being transferred or the code team asking "who is the nurse?" are the report situations that should prompt a more thorough scrutiny of every chart for every patient you take care of. At least make sure the information is jotted down so you can pull it out. Do not, I repeat, do not ever say "uh," when asked a question during these questions. It makes you sound stupid. Either answer the question or say that you are locating the information (and then do it). Another "do not": do not point fingers in these situations. "The other nurse said she did that," or "so-and-so didn't tell me that," although possibly true, help no one right then and also make you look stupid.
- Have an organized way to keep track of patient information.
- Make sure you take the time to get the information you need.
- Never say "uh." Silence is fine, although uncomfortable. "I'll look that up when we're done and get back with you" or "I'm finding that information right now" are much better.
- Don't pass the buck. It's not classy. The mistake may BE someone else's fault, but the time to delve in to this issue is not over a coding patient.