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Monday, February 2, 2015

How to give a good report

I get quite a few questions about how to give a good report, particularly by RT Students.  Here is my pity answer.

Report should not be hard.  What kind of report may depend on who you are giving report to.  If it's the same person you got it from, then you might be able to get away with simply giving the time the treatment was done.  But if it's a different person, you should give more detail.  

Here's what I like in a report for those patients receiving only basic respiratory care (i.e. treatments).
  1. Name of patient
  2. Age
  3. Lung sounds
  4. Vitals (HR, RR, SpO2)
  5. Oxygen (room air, 2lpm, 50%vm, etc.)
  6. Level of alertness (awake, orientated, lethargic, coma)
  7. Anything else that might effect how patient is approached (i.e. hard of hearing, blind, mentally challenged, dementia, depressed, Alzheimer's, nice, mean, laconic, loquacious, etc.)
  8. Why were they admitted (i.e. COPD, Asthma, bowel obstruct, hernia, broken leg, etc.)
  9. Why they are getting treatments (if different from diagnosis (i.e. admitted for heart failure or anemia or bowel obstruction, getting treatments due to asthma history or COPD history)
  10. Are they on oxygen (if so how much and why)
  11. Is the patient stable. This information is helpful in prioritizing what to do first.
  12. Any other pertinent information (going for a bronch today, coughing up yellow or bloody sputum, pertinent lab values, x-ray results, etc. 
What you give in report starts in the report you receive. Write down what you learn.  Check the patient's chart and review doctor notes, lab values, ABGs, x-ray, for anything significant.  Write down what you learn. If the patient has a disease you don't know, look it up on Google.  

Give a pithy report on each patient.  If you are asked a question you can't answer, don't fret.  Most established RTs don't have all the answers either.

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