Master Reports with Picmonic for Nursing RN

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Reports

Reports
Picmonic
Reports are a method of communication that is shared through spoken, written, or computer-based methods. They aid in the continuity of care, and are a legal document providing proof of the nursing care provided. ISBAR is a framework for delivering patient information between members of the health care team. It is broken up into: Identity/Introduction, Situation, Background, Assessment, and Recommendation. Reports are given at change-of-shift, over the telephone or through telemedicine methods, or when a patient is transferred/discharged.
10 KEY FACTS
REPORTING
Shared Communication
Shared Speech-bubble

A report is provided to account for anything that is heard, done or seen. It is communication that is shared through spoken, written, or computer-based methods. Common methods for reporting information include patient records, face-to-face meetings, telephone conversations, written messages and computer messages.  Documentation and reporting aid in the continuity of care, and are a legal document providing a record of proof of the nursing care provided.

ISBAR
ISBAR
Ice-bar

ISBAR is a communication technique used as a framework for delivering patient information between members of the health care team.

Identify
ID

Identity/introduction is where you would communicate who you are, where you are, and why you are communicating.

Situation
The Situation

Situation is where you would communicate who you are speaking about and what is occurring.

Background
Back-ground

The background describes what led up to the current situation, and adds context. Information can be gathered from family, friends, nurses or anyone else who knows the patient.

Assessment
Assess-man

The assessment gives an opportunity for the healthcare professional performing the assessments, usually the RN, to provide their opinion of the problem.

Recommendation
Recommending

Recommendation describes what you would do to repair the problem. Examples would be to use external resources, refer the patient to a specialist, be assessed by their primary healthcare provider, etc.

TYPES OF REPORTS
Change-of-Shift/Handoff Reports
Clocking-out and Handing-off Reports

Information shared at change-of-shift includes; patients name, room number, diagnosis, and health care provider, irregular data, abnormal findings in your assessment, pain level and management needs, current orders, any changes in medication, diet, or activity level.

Telephone/Telemedicine Reports
Telephone and Reports

Telemedicine refers to remote clinical services through the use of technology to communicate between the patient and the healthcare provider, or two healthcare providers. It enables nurses to receive and provide valuable information about patient health instantly. Examples of telemedicine include videoconferencing, email, and phone calls.

Transfer and Discharge Reports
Transfer-train Discharging from Hospital with Reports

Transfer and discharge reports are done when a patient is moved to another unit or facility, and when discharging. During a transfer and discharge report, nurses report a summary of the patient's health and information to the receiving caregiver so that they can provide immediate care.

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