Have you ever gotten a verbal report from a nurse from another health facility that was less than you expected? I have. Once when I called for report on an elderly patient being discharged to us, the RN said to me, “What do you want to know?” I have also heard, “I don’t know much about this patient because this is the first day I have taken care of him.” Excuses don’t work well for me. When a patient is being discharged to our facility, we need to have crucial information to make sure our nursing team can take good care of this patient. Here is a checklist of what to include in a good nurse to nurse verbal report:
Age of patient
Primary health care practitioner
Diagnoses for which patient was admitted to health care facility and past diagnoses/treatment
Progress during admission: results of treatment, reason for discharge
Mental/physical exam: Go from head to toe and comment on:
Cognition: orientation, memory, behavior
Sight: needs glasses?
Hearing: needs hearing aids?
Mouth: needs dentures? Food and fluid intake, ability to feed self
Heart rate and rhythm
Lung sounds: any dyspnea, cough; oxygen amount and when and why worn
Abdominal sounds and palpation, last bowel movement and consistency, continence of urine and bowels, foley catheter use
Lower extremities: presence of pedal pulses, edema
Skin integrity: need for wound care, presence of dressings
Abilities to care for self: transfer, walk, dress, bathe.
Falls: fall risks
Follow up blood work and appointments
Code status: other advanced directives
Mr. S is an 84 year old patient of Dr./NP W’s. He was admitted to our facility due to SOB and was diagnosed with CHF. He has a history of hypertension which is stable. After being diuresed, he is no long dyspneic and is ready to be discharged back to the adult home. He is alert and oriented with mild memory loss. He wears glasses and has bilateral hearing aids. He eats independently with good food and fluid intake. His heart rate is 75 and reg. His lungs are clear bilaterally. His abdomen is soft with positive bowel sounds in all four quadrants. He is continent of bowel and had a formed, soft BM yesterday. He is continent of urine and prefers a urinal he can use independently during the day. He uses a bedside commode at night. His lower extremities show positive pedal pulses with trace edema bilaterally. His skin is free of breakdown except for a 2 cm by 2 cm abrasion on his right knee he sustained during a fall yesterday when he tried to walk without his walker. The abrasion is without signs of infection and covered with a dry, sterile dressing which is changed daily. He transfers with supervision and walks steadily and independently with his walker. He has a BNP scheduled for next week. He will follow up with his primary care practitioner in two weeks.
When a patient is moving from one institution to another, it is the nurses who ensure continuity of care for patients. Next time you are discharging a patient from your facility to another one or are receiving a patient from another facility, use this checklist to make sure you give/get the important information you need to give excellent care to your patient.