NYU Meyers College of Nursing Change of-Shift-Report
List Here: Codes to the staff bathroom: ______med room: _______ pantry: ______ clean supply room: _______
What the previous shift said
□ Check name band
□ De-clutter the room
Patient Name & Age
(Room #)
ALLERGIES
Mental Status
□ NKA
□ Check Allergy band
AOX3 X2 X1 Dementia Non-verbal
Confused
Delirious
Agitated
□ Reorient patient PRN
□ Ask the patient questions
related to their chief complaint.
□ Read the latest progress notes.
Chief Medical Complaint
/Medical Diagnosis
Medical History
(Encircle applicable conditions)
Latest Vital Signs
DM, HTN, CAD, CHF, MI, HLD, CVA,
Dementia, CRF, dialysis, PNA, UTI, COPD,
Asthma, Falls,
□ Ask the patient questions related
to their medical history.
□ Read the latest progress notes.
BP HR RR Sat O2 Temp. -
□ Read the latest progress notes.
□ Take vitals ASAP and compare with
previous readings.
□ Patient on tele, V/S Q 4 hours
Telemetry -
Fingerstick □ Post-pain meds pain level
□ offer pain meds
Pain Assessment
IV Access
(Date Inserted, Type of Fluid, Rate)
Diet/Nutrition
Tube Feeding
Lt Saline Lock
Rt Saline Lock
□ Flush Saline locks – 3 ml NS
If not needed D/C IV line
□ Update I and O
Peg/NGT –
□ Residuals –
□ NPO
Nasal Cannula – ____ L/min
□ Check Residuals Q 4 hours
□ “Water your patient”
Foley –
BM –
Hemovac JP -
□ Update I and O
□ Check if your patient is wet/dry
Oxygenation
Output
(Foley Catheter, BM, Ostomy, NGT)
Latest Lab Results
Skin Integrity
Quality/Safety Checklist
Na KCl CO2 BUN Creat Intact
Stage 1
Stage 2
Stage 3
Stage 4
□ Incontinent
□ Independent
Ca –
Hgb Mg –
Hct PO4 –
Plt INR –
Albumin –
PTT –
Glucose □ Unstageable -
Ask: “What’s the evidence-based plan for this patient?”
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□ Check behind the ear if on Nasal
Cannula
□ Encourage use of spirometer
□ Compare current result with
previous ones.
□ Find explanation for lab abnormalities
□ Turn your patient!
□ Get patient OOB
□ Braden Score
□ Keep heels off the bed
Hourly Rounding
□ Pain
□ “Potty”
□ Positioning
□ Personal Effects/pitcher
Some Suggestions for Non-stop Life Saving While You are in Clinical
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Perform hourly rounding and address the four “Ps” – pain, potty, position, pitcher
De-clutter and Feng Shui the patient’s bedside (example: remove dead plants)
Read your patient’s chart – you’ll learn a lot reading progress notes
Ask your peers “Do you need help?” “Is there anything I can do for you?”
Check your patient’s lab works – what do these numbers really mean?
Ask a clinical question – or ask the Staff Nurses (they are wonderful resource)
Talk with your patients and family – great teaching opportunity
Offer your patient and other patients something to drink – think of “Happy Hour”
Turn your patient to sides every two hours – Saves the patient’s skin and yours too
Keep your patient’s Head of Bed up to 30 degrees – this will prevent aspiration
Keep both heels of your patients off the mattress – prevents heel ulcers
Brush your patient’s teeth – good for bad breath and beyond
Date/Time
Ex. Jan. 30, 2012
12 noon
DATA
Sample Note for a Patient
with COPD
AOX3, Bilateral wheezing,
O2 sat 94% on 2LNC,
dyspnea on exertion,
productive cough with
whitish-yellow secretions,
cool to touch both lower
extremities, poor appetite for
breakfast and lunch, refused
to get OOB, uses bedpan with
assistance.
ACTIONS
Kept on 2LNCwith
humidifier, kept upright in
bed, pulse ox monitored Q 4
hours and PRN, encouraged
fluid intake and assisted with
meals, chest PT done,
emotional support offered to
patient and family, provided
literature on COPD and
RECOMMENDATION encouraged to ask questions.
No signs of respiratory
distress, O2 sat stable at 92 to
96%, No SOB at rest, stable
vitals, sleeps at short
intervals, complaint with
meds but has poor appetite,
will continue to monitor, MD
is aware of patient’s status.
Your Draft