End of shift report!

[NikkiJazzz]

Hello fellow students. My name is Nikki from San Diego, Ca. I am in my advanced med-surg rotation and I am having a hard time trying to find a way to give an "end of shift" patient report. Does anyone have a format/dialouge that they can share? Thank you
very much
-Nikki

[ICUnowOHN]

I usually start with pt name and primary dx. then review relevant body systems.

i.e. Mrs. Bleedingheart is second day postop from MRx4 by Dr. Fatal. on 6L simple mask, 02 SAT 99%. give lung sounds, cardiac rhythm, has D5 1/2NS w/ 40Meq of K+ at 60. K+ 3.9, had chest tubes out this AM, central line also pulled today. has been up to restroom x2 with assist. no difficulty urinating, bowel sounds hypoactive. Diet is clear liq, may advance as tol.

Just pick a method of getting the pertinent info out, take your time. Take some of the ideas the nurses you are working with...

I used to do 12 pt/shift with a CNA, or if I was really lucky, I got the LPN.

[yazz]

I was told start from the top of the patient and go down

"pt full aware, speaks in full sentences.
pt breathing normally (i won't use to many abreaviatioins as I don't know if they are the same for you across the water) patient still has legs"

By the way if that is wrong please don't shoot me, english students don't get much time on clinical placements. This is my first placement of the second year and I am only getting 8 weeks in each placement, hope that helps