How to Give Report

Who you are handing off to, the quick essentials, the thorough breakdown, what not to forget, and what a critical patient adds.

How to Give Report

The first thing to consider is: who are you giving report to? • Some ER nurses prefer a short and sweet handoff. • Tele or ICU nurses will expect a more detailed report, and they'll likely ask a lot of follow-up questions. • Med-surg can be hit or miss — some want the full picture, others just the essentials. If you're new, don't be afraid to say: "Hey, I'm still learning — if I miss anything or if you have tips, I'd appreciate it!" This not only shows humility but can set a positive tone and reduce pressure on you.

Quick Report Essentials

Even a concise report should include the basics: • Name and age • Chief complaint • Pertinent medical history • Allergies • What was done in the ER (brief summary) • Pending items (labs, imaging, consults) • Disposition plan (admit, discharge, or pending dispo) ("Dispo" refers to what's going to happen with the patient next.)

Thorough Report Breakdown

A full report includes everything above, plus: • Associated symptoms (chest pain, SOB, nausea, etc.) • ER treatments (meds given, fluids, interventions) • Pertinent labs (focus on relevant or abnormal results) o Example: Chest pain? Mention troponins and if they're pending or trending. • IV access: Size, location, any infusing meds • Last vital signs • Neurological status: AAOx4, GCS • Respiratory status: Are they on oxygen? Room air? BIPAP? o Example: "Pt is AAOx4, GCS 15, c. respirations even and unlabored at this time." If you gave sedating meds like benzodiazepines, note the time given — it explains any drowsiness or altered behavior.

Don't Forget

• Code status • Tubes/Devices: Foley, NG, chest tube, ostomy, fistula, pacemaker, AICD, amputations • NPO status and why • Medication schedule for the oncoming shift • Allergies and PMH (pertinent past medical history)

For Critical Patients

• Pressors: Name, current dose • Intubation: ET tube size and length • Sedation: Meds and response • BIPAP: Settings and tolerance • Lines: Central line (location, type), arterial line, etc.

Final Tips

• Do bedside report whenever possible: o It reassures the patient someone is taking over o It reduces liability if a change happens right after the handoff o For neuro patients, do a joint assessment to establish a clear baseline • Always document report in your notes: o "Report given to RN Smith. Questions addressed. No acute changes noted." • If you forget something, don't stress — the oncoming nurse will ask questions, and that's part of a good handoff.

How to Give Report