Getting the right report

One of the most nerve-wracking parts of the clinical day is the very beginning. Even if you’re working on the same floor the whole quarter, it’s quite unlikely you know everyone on the unit. We scramble to find out which nurse is assigned to our patient in a sea of tired night shifters and not-quite-ready for an eager student day shifters. And we’re looking for new orders on our patient, while trying to figure out where everything is and not looking lost all at the same time. In the morning rush, it seems like the one place where everything would come together would be in the morning report, but that’s not always the case.

As a student, my BIGGEST pet peeve is when you get morning report from the night shift nurse and all they do is read off the patient’s H&P. Since we’re the ones going in the day before to spend hours reading the patient’s chart, their day-by-day progress, and their entire medical history, we’ve already got that part down. I get that the morning nurse maybe hasn’t read the H&P yet, but that’s something he or she can do after report, I mean, we are all trained at how to find things in the computer, or can certainly flip to that section in the chart on our own accord. When you get report in the morning, the point is to “hand-off” the patient, not read off material that the MD wrote out ten days ago when the patient was admitted.

We don’t want to start the day off on the wrong foot with the nurses, but it’s our responsibility to get the right information we need on the patient. What’s been happening in the last 12 hours? Did anything significant occur? What meds is he requesting? Is his output ok? The questions we need answered will vary depending on the patient and the setting, but it’s these updates that are vital to the way we start our day and care for our patients.

So what can we do?  Well, you don’t want to be rude about it, so no yelling out, “YES, I DO KNOW HOW TO READ, thanks, I will do that on my own time” (no matter how loudly you may be screaming it in your head). But it’s important to be prepared for report. Have your paperwork ready, use a “brain” to organize yourself, and where there are gaps in your papers, ask questions (nicely!). There are plenty of reasons why report gets read off the chart in the morning, and I don’t mean offense to any nurses who refer to the chart during report, I am strictly talking about the nurses I have seen who solely read off the chart for their report. I have even had nurses say, mid-sentence, “well, you know, you can read the rest of this later, ok, any questions?” If this happens jump to it and take that opportunity to get your questions answered.  Getting a full and thorough report is just as much your responsibility as it is the other nurse’s responsibility to give it. Make sure you’re getting your questions answered so you can start the day off with one less bit of confusion on your mind!