Reporting Tips (1) Start with the basics: Pt Name Age Code Status Diagnosis Surgery (if applicable) with post-op day Allergies Medical History Any precautions (Droplet, Contact, etc). Mobility Status (2) Then think: head-to-toe Neuro: Are they oriented to Person? Time? Place? Any neurological deficits? (if not - don’t have to include that they have “none”) Resp: Are they on any oxygen? How do their lungs sound? Are they coughing? Do they have any puffers that they are using? Do they have an abnormally high or low resp rate? CV: Are they on telemetry? What is their rhythm and rate? How is there blood pressure? (This is a good time to mention what their “normal” is- i.e. they normally sit around 130 systolic and 90 diastolic) Do they have a fever or temperature? Do they have pacer wires? Do they have any edema, if so, where? Any abnormal lab values (i.e. Hbg is low, potassium is high, etc) GI: What is their diet (full fluids, cardiac, etc)? Fluid restriction? Any nausea/vomiting? What does their stomach feel/look like? (distended, round, etc) When was their last bowel movement? If diabetic - how have their sugars been? (high, low, normal, etc.) GU: How are they urinating? Do they have a foley? Commode? Independent to the bathroom? How has their output been? (adequate, low) Is the urine a strange color or odour? (amber, blood tinged) Are we closely measuring ins/outs? Tubes/Drainage: Do they have chest tubes? If so - how has the output been over the day? Any other drains (JP, Hemovacs)? Skin: Mention dressings (i.e. sternal incision, chest tube sites, endoscopy sites) Any drainage on sites? (i.e. needed to be changed multiple times during the shift) Any other skin breakdown sites, coccyx ulcers, etc. IV Access: Peripheral IVs Central lines Pain -Is the patient having any pain? -What are they taking for pain? -Any other relevant medication information (i.e. They are being started on warfarin tonight, they have a special medication that you will have to call pharmacy to have prepared, etc). Other relevant information: -Did they go for any tests today? -Are there any consults to other teams that are relevant (endocrine, neuro, etc) -Family information -What is the plan for the patient? (home tomorrow? Continue to rehab/mobilize/etc).
