HOW TO G IVE AN ORAL

REPORT T O THE
REGISTERED NURSE

Fitrawati Arifuddin
2016
 CASE
John, an ICU nurse, quickly transfers
a stable patient, Henry Richards, to the
stepdown unit to make room for a
critical patient admission. He tells
Louise, the stepdown nurse, "My
admission is here, so I don't have time
to give you a report right now. Look
over the care plan and give me a call if
you have questions."
 ORAL REPORT
A verbal
report If
So,, how to
done give a
poorly,
verbal
reports
It can wastes
time, high risk quickly and
of patient accurately?
critical state,
and can even ?
jeopardize
patient safety.
 A G O O D V E R B A L R E P O RT
SH O U L D IN C LU D E T H E
F O L L O W IN G :
Basic information. Begin with the patient's name, room number,
age, date of admission, and the name of the attending physician.
Then give the diagnosis or the reason for the hospitalization.

Patient status. Give an accurate assessment of the

patient's current condition. Include such information as
major fluctuations in weight, vital signs, and lab results.
Interventions and response: Describe any new orders
or discontinued orders. Are there scheduled labs or tests?
 VERBAL REP ORT S: BE
PRECIS E AN D CON CIS E
Include :

Basic patient background

Equipment and IV
information
information
Diagnosis
Significant lab results
Treatment plan
Changes in status
New orders not yet transcribed
Pain levels and treatment
Mental status and activity level
Response to new
medications/treatments
 DON'T INCLUDE
Lengthy or rambling comments

Speculative material

Irrelevant or outdated information

A description of nursing activities unrelated to

the patient's care
Inappropriate comments about the patient's
family or doctor
 RE P O RT E XA M P L E
"Baby boy Nelson is a 32-week, 6 lb, 7 oz preemie, delivered by vacuum
extraction on August 10th. There was thick meconium at delivery. The
baby was immediately intubated and suctioned, to remove a small
amount of meconium. Grunting and retractions were immediately
observed, with O2 saturations between 72% and 78%. His Apgars were
5-7-9, with poor color and muscle tone.
"The baby was placed on CPAP for 72 hours, with occasional
desaturations and spontaneous recovery to 96% 98% oxygen.
"We initiated a sepsis workup and he was started on IV ampicillin and
gentamicin q12h. The IV was restarted this morning at 8 a.m. The site
is patent and was last flushed at 1 p.m., after his fourth gentamicin
dose. Next dose is due at 1 a.m. He was placed on O2 2L/NC yesterday
and has had no desaturations. His vital signs were axillary temperature
98.2 F (36.6 C), HR 144, and RR 60.
 CONTINUE...
"This baby's mother is a first-time mom, so she has lots of
questions. She tends to visit around 3 p.m. and likes to do
kangaroo care. Baby Nelson is on breast milk with fortifier and is
taking 38 ml PO every three hours, with good nippling. He was
last fed at noon. He had two wet diapers and one BM today.
This report is consice and to the point. In just two three
minute. The nurse in the stepdown unit receive an accurate and
complete picture of her patient and his current status.
THANK YOU