By: Amanda Kammes, MSN, BSN, RN – Go4 Nurse Community Manager
Taking report is arguably the most mundane, but also one of the most important parts of handoff. Handoff, which typically occurs on any unit in a hospital around the hours of 7a or 7p, is a hectic time. The day shift nurses are leaving and ‘handing off’ their patients to the night shift nurse and vice versa going from night to day shift. The techs also cycle in and out on a similar cadence in most units.
For me, the nurse report sheet was too involved. I needed one piece of paper where I could have all my patients for quick review and small enough to be folded and put in my pocket as I set off to see my patients for the first time. I did need a review of systems, drug allergies and a little synopsis of their background, but I needed it all to be short and sweet.
Every nurse will find their own mojo here. My way isn’t necessarily the best way or even what ultimately would be your way–but after a deep dive into the existing literature, I feel confident that my way was in fact, one of the best options out there.
So let’s get started:
- Grab a piece of paper from the printer at your front desk.
- Fold that paper into fours so that there are now 4 quadrants on the blank paper.
- In the top left corner of each quadrant, write your patient ROOM NUMBER. Write their LAST NAME next to the room #.
- Finally, to the far right, list their code status- FULL or DNR
- Under that list any allergies they may have; if none NKDA
- Under allergies, begin your systems list. This can go in any order, but the key here is to list them all. I often wrote them in a head to toe fashion.
- Neuro (head)/ cranial nerves/GCS/ AAOx3 etc
- Cardiovascular- heart issues/ BP/ HR
- GI- diet/ any speech or swallowing issues/ peg tubes/ feeding tubes etc
- Respiratory- O2?/ lung issues/ trachs/ chest tubes
- GU- bathroom priv/ foley/ fluid restrictions etc
- IVs- do they have any and if so where and what gauge? Any that are expiring? What lines do that have running?
- Drains- location, how many, output
- At the bottom I always listed the service they were on and also the pager number. This made calling a Resident or Attending quickly if I needed assistance in a pinch.
- Finally, I would always put them in the order of most critical in the top left and then work clockwise down. My patients that were walkie talkies or that should be getting discharged soon always went in the bottom right corner.
- When you are done getting report, fold the paper in half lengthwise and then half it again vertically and you ready to go!
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