Reporting lecture

Question 1

what is the best format for giving report

Answer 1

SBAR
situatino
background
assessment
recommendation

Question 2

what should a complete report reflect

Answer 2

• careplan/progress toward goals
• length of stay
• discharge plans
• risk management/saftey issues(falls/combative)
• interventions
• treatment changes
• psycho-social issues
• pertinent lab/diagnostic reuslts
• infection status
• allergies

Question 3

when are times report is given

Answer 3

• change of shift
• meal breaks
• transfer to other units
• when pts taken to procedure
• discharge to outside facility(prison/snf)

Question 4

how long should average report time be

Answer 4

No longer than 10 minutes! on med surg

Question 5

what does the situation section include

Answer 5

pts name age room #
admit dx
code status-if pertinent
allergies
physician(if oncall doc is not the one)
what is happening now for the call

Question 6

what is included in background

Answer 6

Pertninent:
med hx
vitals/trends
pain-recent PRNs
labs/tests
special needs
consults-ordered/pending

factors leading to this event

Question 7

what is included in the assessment

Answer 7

brief systems review
iv /tubes, drain/ dressing
assessment findings
condition changes
infectino status
interventions/outcomes

what do you see/what you think is going on