Transcript Intern Survival Guide: Ward

Intern Survival Guide:
Ward/Night Float Edition
Outline
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Introduction
Schedules
Prep work
Division of labor
Where things are
When things happen
AM Sign-Out
Work Rounds
Morning Report
Attending Rounds
Private PMDs
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Orders
Admissions
Progress notes
Discharges
Running the List/Updating
Medical Students/Teaching
PM Sign-Out
Weekends and Holidays
Night Float
Misc tips, tricks and advice
So you’re starting the floor…
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The pediatric ward is located on 11N, to the left
of the elevators.
The resident call room is the first room to the
left as you walk through the double doors onto
the floor. Please ask one of the seniors or the
chiefs for the code.
Dress code is business attire ± white coat. If
you’re on call on a Friday night, you can change
into scrubs before sign-out. If you’re on over
the weekend, it’s all scrubs, all the time.
Floor Intern
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For 3½ months, you belong to the 11N floor team as their
intern. The rotations are labor intensive (and very intimidating at
first!) but can be very rewarding.
The floor team will consist of medical students, 4-5 interns
(usually 3 or 4 pediatric interns + 1 family medicine intern) and 2
seniors.
Patients will be split as evenly as possible, but expect to carry at
least 4-5 per day on average. During the busier months, this
number can easily double. Time management will likely be the
most important thing you learn your intern year.
Remember – you play an active role in your pediatric education,
of which the inpatient rotation is an important piece. Please feel
free to ask ANY AND ALL questions you may have.
Scheduling
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During each month of floor rotation, your work hours are
officially 7am (AM signout) – 6pm (PM signout).
For every four weeks that you’re on the floor, you’ll work a 24hour Friday, a 24-hour Saturday and a Sunday (7am-7pm)
Be prepared to push the 80-hour work week limits. Sleep when
you can, eat when you can, and don’t forget to keep yourself
hydrated.
Schedule Access
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To access your personal schedule, go to:
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New Innovations:
https://rms1.newinnov.com/Login/Login.aspx
After logging in, hit
View:
Take a couple of hours one day and just browse
through new innovations. It does take some getting
used to.
Preparation
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Before you start the floor, familiarize yourself with
where everything is. During orientation week, take the
time to really be nosy and look around at everything.
Get a sturdy binder or clipboard, black and colored
pens and a small calculator (Staples has cute keychain
calculators for $1.)
The day before you start, one of the other interns will
sign out their patients to you. Make sure that you know
everything about each one of those patients: take notes
during the verbal sign-out, comb the chart for pertinent
information (H&P and off-service notes are key, if the
latter is applicable) and go through the computer for
current orders, latest labs and previous discharge
summaries, if there are any.
Flow Sheets
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Flow sheets are found either in the big
cabinet on 11N or @ pedsportal.
fellinahole.com under “chart data.”
They exist to have all pertinent
information, past and present, at
fingertips and facilitate good signout.
Most interns like to use them and you
should receive one for each patient
you are signed out, but there are no
guarantees. A good rule is to make a
new one for each patient you’re signed
out, as well as new patients you’re
assigned.
You should hand them off to another
intern whenever you need to sign out
(to night team, when you have clinic,
off-service). Make sure they’re legible!
Where Things Are: Charts
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Red Charts are usually found next to the clerk. In them you’ll
find:
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Patient stickers
Completed H&P with growth chart
Progress notes
Completed consults
ED and outside records
Blue Charts are found bedside. They house only asthma scores.
Powerchart: our electronic medical record
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Orders
Meds/MAR
All vitals (including height, weight and HC) and I/Os.
All patient results including radiology (PACS) and old records (Eclipsys)
Where Things Are: Miscellaneous
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Forms/Paperwork:
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The big gray cabinet in the core houses most of the blank
forms you’ll ever need, including blank H&Ps, flow sheets
and discharge paperwork.
If you need paperwork not found in the gray cabinet for any
reason, ask a clerk or your senior.
Other Items in the Core:
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Big bulletin board
Frequently called phone numbers
Frequently written orders/fluids
Printer/Fax machine
Frequently Called Numbers
Floors
Labs
Radiology
Faxes
11N – 4-1152
11N core – 4-1169, 4-8148
11S/PICU – 4-1100
11S/HemeOnc – 4-1101
11N call room – 4-3884
11N conference room – 4-2419
NICU – 4-2001
Nursery – 4-2110
Peds ED – 8-3500
OR – 4-2444
Admitting – 4-2591
Blood bank – 4-2626
Chemistry – 4-2365
Cytogenetics – 4-2749
Cytology – 4-2216
Hematology – 4-2375
Histology – 4-2236
Immunology – 4-2231
Microbiology – 4-2370
Phlebotomy – 4-7626
Virology – 4-2374
PFT – 4-1765
EEG – 4-2260
EKG – 4-1760, 4-5481
Echo – 4-1770, 4-3769
CT– 42408, 4-3715
CT ER – 4-9002; 4-8150
MRI – 4-2515
Neuroradiology – 4-1443
Peds Radiology – 4-7227
Radiology JR – 4-7450
Radiology SR – 4-7451
Radiology Supervisor – 4-7453
Reading room – 4-2882, 4-9514
Ultrasound – 4-7455
X-ray – 4-5056
X-ray tech – 4-7453
11N – 4-1355
PICU – 4-8983
CT – 4-6237
MRI – 4-8959
Tech Park – 4-4990
Patchogue – 4-6327
Islip – 581-9561
East Moriches – 878-8084
Clinics
Clinics (appt) – 444-KIDS
Tech Park – 4-0651, 4-4601
Patchogue – 4-6319, 4-6314
Islip – 581-9330
East Moriches – 878-8050
Pharmacies
Pediatric 8-2420
Adult – 4-2680
TPN – 4-1440
Operator: Dial 0
4-6000
4-7788
Other Services
Child Life – 4-3840
Dietary – 4-1440
Dietician – 4-1436
PT – 4-2620
OT – 42533
Transport – 4-2980
Medical records – 4-1300
Social work – 4-2552
Infection control – 4-2239
Child psych – 4-1250
Patient relations – 4-2880
Misc.
Elaine – 4-2020
Computer help – 4-HELP
NB screen (LIC 211855) –
518-474-1753
800-535-3079
Poison control
516-542-2323
800-222-1222
SB Pharmacy – 751-4477
American Red Cross (CPR)
924-6700
When Things Happen
Daily
Prior to 7am:
Preround
7am – 8am:
AM sign-out and work rounds
8am – 9am:
Morning Report (except Wednesdays, Grand Rounds)
9am – attending rounds:
Work
Midmorning:
Attending Rounds
Midmorning - 6pm:
Work
6pm:
PM sign-out
Throughout the day:
Update your senior!
Weekly
Tuesdays at 2pm
Chatting with Chandran
Thursdays at 10am
Chairwoman’s Rounds
Weekly at 10:30am
Subspecialty Rounds
Weekly
Intern Symposium
Biweekly
Intern Morning Report
Pre-Rounding
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When you’re ward intern, what time you arrive at the hospital is usually
dependent on how many patients you carry. Plan on being there at
approximately 6am.
Find the night intern and nurses to get sign-out on overnight events.
Obtain vitals (including ranges if abnormal), ins and outs, asthma
scores, new labs, etc. Look at radiology studies done overnight (don’t
just read the report).
See all of your respiratory kids and as many other patients you can
before AM sign-out. Patients with acute issues should have priority. If
the patient is sleeping, you do not have to wake him/her for a full
physical, but when pertinent, do a focused exam.
Tip: Organize yourself while pre-rounding in order to prepare for
work rounds. Either on your flow sheet or your own sheet, write a
one-sentence summary about each patient, vitals and labs you’ve
collected and current medications. Start a checklist for what you
foresee to be the day’s plans.
Pre-Rounding: Personal Flow Sheet
Example
AM Sign-Out
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AM sign-out begins promptly at 7am in the 11N
conference room across from the call room. It’s
extremely important to be on time for every
scheduled event, including this one.
Assigning patients: As the night intern presents new
admissions (more information on this later), the seniors
will assign them to interns based on current patient
numbers. Take note of any service/staff patient you’re
assigned, as those require a little more work.
Work Rounds
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The entire team (including night intern and senior) round in the
conference room in the morning as an introduction for the day.
Presentations should be short, with a brief introduction to the
patient, any overnight events, ROS by system, pertinent physical
exam findings if you examined the patient, pertinent vitals,
assessment and plan for the day.
Tip: When presenting vitals, include asthma scores, ranges (if
pertinent) and UOP in cc/kg/day (this is especially important in
our nephrology patients).
On Wednesdays, work rounds are conducted one intern at a
time in the 11N conference room in order to make sure
everyone can get their pressing work done and make it to Grand
Rounds on time.
Senior Sign-Out
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 Tip: Try to structure your presentations for work rounds by
systems as laid by the senior’s sign-out sheet.
“Patient BC is a 10-month-old male with rotavirus + AGE, hospital
day 2. No overnight events. Patient is on a regular diet and ½
maintenance fluids. Tolerating PO well, no vomiting. No respiratory
or cardiovascular issues. Vitals are [here, including the weight and
change], with a UOP of 2cc/kg/hr. Had 3 episodes of diarrhea
overnight, which is improved over yesterday. Plan is f/u stool studies,
heplock his IV today, monitor Is/Os, discuss with Dr. Baram possible
d/c.”
Be prepared to move fast – the team has to round on the entire floor
before morning report.
If rounding is not complete by 8am, rounds conclude after morning
report in the 11N conference room, one intern at a time.
Morning Report
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The goal of morning report is to provide an interactive forum for house staff
to develop skills in presentation, diagnostic evaluation and patient treatment.
It is run by the chief resident with multiple faculty, including Dr. McGovern,
present.
Cases are usually selected by the chiefs with input from the current seniors.
Seniors should share their knowledge with the interns and the interns should
feel free to ask questions and offer responses.
As a new intern, you will not be expected to present. In your last six months
of internship, however, the baton will fall to you. Therefore, you should pay
attention to your seniors – how they prepare, present and respond to
criticism.
In general, presentations should include the chief complaint, a chronologic
HPI (what happened at home, then at the outside hospital, then at our ED),
past history, chronologic physical exam (did yours look different from the
outside hospital?), any and all labs/diagnostic done.
Comprehensive treatment of entire topic is not necessary but all possible
entities in the differential diagnosis should be discussed based on the facts of
the case at hand.
Morning Report: Running the List
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Before cases are presented, the chiefs will run the list of
patients who have new and/or interesting radiographs.
After cases are presented, the chiefs will prompt the interns
to run the entire list.
For either of these situations, be prepared to give a oneliner about your patients: “Patient JJ is a 7-year-old male
admitted with a left surpacondylar fracture after falling from
a trampoline, now s/p CRPP.” ( Tip – always include
mechanism of injury).
On Mondays, we run all admissions from Friday through
Sunday. If you are on over the weekend, keep a list handy
(usually taped to the cabinet above the senior computer) of
patients you admit.  Tip - Don’t forget about the patients
admitted Friday night that are discharged on Sunday!
Attending Rounds
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After morning report, you should get all time-sensitive work done: discharges
(should be done before 11am if possible), calling consults, seeing newly
admitted patients (with service patients getting priority) and reading their
charts thoroughly, and seeing all service patients.
Attending rounds are bedside and family-centered with presentations either
outside of the patient’s room or inside with family present.
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If the patient is established, your presentation will be the same as work rounds,
except your emphasis will be on physical exam, assessment and plan.
If the patient is a new patient, you will have to present the entire H&P.  Tip –
Because the hospitalist will physically take the H&P from a newly admitted
patient’s chart to write on, you should either photocopy it or take good notes
from it before rounding.
You should defer all presentations to your medical students if they are
following a patient with you (this is true of work rounds as well). Make sure
to go over with them the correct format and help them in their areas of
weakness.
Private PMDs
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Some community pediatricians have admitting privileges. If a
patient is admitted under a private PMD service, that PMD is
their attending.
The physician “on-call” to the hospital will usually round in the
morning (usually at exactly the time of work rounds). They will
drop by the conference room to pull out the night intern/senior
in order to impart the plan for the day.
Because there are no formal attending rounds with private
PMDs, you should have a low threshold for calling them during
the day when any situation arises.
For a list of PMDs and their contact information, check out
fellinahole at http://fellinahole.com/peds/pmd.html.
Tip: Most will appreciate being updated at least twice during
the day – once in late morning and once in late afternoon.
Orders
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All order writing is now done electronically through our CPOE
system. Please refer to your PowerChart training for more
specific instructions.
You should notify the patient’s nurse of any new orders, especially
if the order is written as STAT.
Lexi-Comp online (http://online.lexi.com/crlonline) is our
hospital approved reference for medication.
Since CPOE has eliminated order rewrites, it is prudent and
necessary to check every order every day to make sure that you
haven’t hit a soft stop or fallen off of the MAR.
Compare active orders to what the patient should be getting to
exactly what the patient is getting (MAR) every day.
More Orders
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Orders that need to be renewed daily: Restraints, 1:1 orders.
Orders for phlebotomy need to be put in for the exact times of
6:00am and 11:00am (when the phlebotomy team rounds).
These orders should ideally be put in the night before, but if that
is not possible, make sure to give the phlebotomists enough time
to see your order.
If you are too late for phlebotomy or would rather have the
nurses collect blood for you, put in the order as a “nurse collect”
and tell that patient’s nurse.
Our nurses are very professional and will place IVs, draw blood
and place catheters for urine when necessary.
Radiology
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After putting in orders for desired study, call the
appropriate department in order to make sure they are
aware. Try (and it may be difficult) to get an estimated
time that the study will be done.
If contrast is to be given, obtain parental consent and
place it in the chart.
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You should discuss with your senior resident whether the
patient should be NPO for the study, but in general:
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Patients who need studies under anesthesia and patients who need
CTs with contrast will need to be NPO for a certain amount of time
before the study (usually 4-6 hours).
MRIs usually do not require a patient to be NPO.
If a patient requires anesthesia, call the anesthesia coordinator
and he or she will help you arrange the study.
Prescription Writing
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Use the hospital DEA number (AU9053125) and your personal
suffix at the top of the script. Always stamp at the top.
Medicaid patients require an attending license number to be
written at the top. License numbers can be found here:
http://www.health.state.ny.us/professionals/doctors/conduct/
Prescriptions do not need to contain any math but they do need
to specify what the concentration is of any suspension or tab/pill
you write for:
Amoxicillin 400mg/5ml suspension
Sig: 6mL PO BID for 10 days
Disp: QS
Consults
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When arranging for a consult, page the resident or fellow
covering for that service. If there are no residents or fellows,
page the attending directly.
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Exception #1: If there are no ophthalmology residents seeing pediatrics
patients, consults are attending-to-attending.
Exception #2: ENT consults are always attending-to-attending.
Exception #3: Cardiology and child pysch consults are arranged via
their main offices. To consult either one of these services, have the
operator connect you to their main office.
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 Tip: Before calling a cardiology consult, you should obtain an EKG and
4-limb blood pressure. They are always helpful!
Fill out the top part of the consult form and leave it in the chart.
Never call a consult without attending approval.
Never initiate a plan proposed by a consultant without attending
approval.
Admissions
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Patients who are admitted during the day to a general
pediatric service (service, private PMD, non-surgical
subspecialties) will require:
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A complete history and physical, after which an H&P
packet needs to be completed.
Growth chart and BMI
Admission orders
PMD notification
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PMDs need to be notified of admission both when they are the
attending and when they are not.
Any private pediatrician of a service patient or patient from another
service (ie surgery, ortho) should be notified of admission.
Medication Reconciliation (if not done by nurses)
A flow sheet
Admissions: Other Services
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Surgical services
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We “co-follow” pediatric surgery, orthopedic, OMFS (etc)
patients. When they are admitted, a full H&P is not required
– only an accept/post-op note is required.
Daily SOAP notes are also required.
Patient issues or questions about plan of care should be
discussed with the primary team.
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Orders should not be written on their patients without their approval,
but you should check to make sure they are correct.
The reverse is also true: surgical teams should not be writing orders
on service or private patients that they may be consulting on. Please
contact your senior or chief if this happens.
We are involved with surgical patients as we are on the floor
24/7 and they are often in the OR when situations arise.
Admissions: Other Services
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Neurosurgery
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Same as surgical services. The only difference is that the pediatric
neurosurgery service often requires a “pediatric” consult.
 Tip – Write your accept/post-op note on the consult forms.
Any questions should be directed toward your senior or Nancy
Strong, the pediatric neurosurgery NP.
ENT
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ENT patients are often admitted under the hospitalist service.
Therefore, they do require an H&P packet, daily SOAP notes and
orders (though they should not be written without ENT attending
approval).
You are not responsible for discharging or dictating the patient. A
surgical resident will complete the discharge paperwork and dictate.
Admissions: The H&P
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You are responsible for doing admissions with the senior
resident and medical student (if you are assigned to one.)
At that time, you will ask the questions regarding the history.
(After your medical student has watched you do this once or
twice, you should pass the baton to him or her.)
You will all complete the physical together.
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 Tip – Don’t forget the oto-ophthalmoscope to examine the ears and
the pharynx. Check to see if there are pediatric otoscopic specula (the
smaller ones) and tongue depressors with the scope before you go in.
Your H&P format will be laid out for you in our easy-to-use preprinted intern packet.
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 Tip – Sticker every page, back and front.
 Tip – Until you get comfortable writing a chronological, sensible HPI,
take notes on the back of the intern flow sheet. You can transcribe it
later and have the extra bonus of having an HPI at your fingertips on the
flow sheet.
Progress (SOAP) Notes
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There should be a progress note in the chart for each patient every day.
 Exception: If the H&P of a new patient admitted overnight is dated after
midnight, a SOAP note is not required.
In the first line of the note, remind the reader why the patient was admitted:
“7-year-old with reactive airway disease exacerbation and hypoxia.”
The SOAP format:
 S (subjective): How the patient did overnight, any events, any complaints.
 O (objective): Physical exam including ALL vitals (weight, I/Os), labs,
radiology.
 A (assessment): Summary of status.
 P (plan): Goals by systems
  Tip – It helps to arrange your systems by the order they are laid out
on the senior signout sheet. (FEN, Resp, Cardio, ID…)
Date, time, stamp and sign every page of your progress note.
All notes by medical students should be reviewed, discussed and co-signed
before being place in the patient’s chart.
Discharges
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To discharge a patient, you must complete a discharge summary
(found in the gray cabinet in the core), write necessary prescriptions,
and arrange follow-up with PMD.
Contact all consulting services at point of discharge and ask if they
would like follow-up if not addressed in their note.
In theory, the discharge paperwork should be started as soon as the
patient is admitted so that completion does not delay discharge.
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Keep incomplete summaries in the top left desk drawer in the core.
Make sure there is enough information on each summary so that a resident
covering you over the weekend or while you are at clinic is able to discharge
the patient successfully.
Make sure to write your name under “responsible dictating resident.”
The discharge sheet serves as the progress note for the day.
After the patient has been seen by the attending, sign the discharge
summary and put discharge orders into the computer.
Discharges
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If a patient is going home on an unusual medication, call the
outside pharmacy and make sure they will have it available in a
timely manner.
If the pharmacy is closed or will not have the medicine in an
acceptable period of time, see if there is a spare dose in the
patient’s drawer to get them through the day and/or the next
morning. The pharmacy supervisor is also sympathetic to the
realities of these situations and will sometimes agree to send
up an extra dose or two before discharge.
Magical pharmacies that seem to have very unusual
medications are Stony Brook Pharmacy (no affiliation) and
Fairview Pharmacy.
Dictations
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All patients admitted for more than 48 hours will require a
dictation.
 Tip – Try to dictate patients in a timely fashion, optimally
before the charts leave the floor. After that, you must head up
to the 13th floor to medical records and have your charts pulled
for you to dictate.
The rules:
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You may have no more than twenty on your list until January 1st
(then no more than ten thereafter).
You may not have any chart older than 30 days on your deficient
list.
If any of these rules are broken, medical records will contact Elaine
and put a letter in your mailbox threatening suspension of medical
privileges, fines and other bad things. In addition, the chiefs may be
forced to give you an extra call.
The bottom line is – get your dictations done.
Dictations
Transfers
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Accepting a Transfer
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Usually from the PICU
Read through chart thoroughly, including the other service’s transfer note.
Talk to the patient, get history, do physical.
Double-check already written orders.
Write an accept note. Make sure to include the hospital course until the
time the patient is transferred to your service.
Transferring to Another Service
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Usually to the PICU
You MUST write a transfer note, which is SOAP note format with more
detail. Include a brief HPI and hospital course until time of transfer.
Write transfer orders in PowerChart
Reconcile meds using the “transfer” option.
Sign-out to the resident accepting the patient.
Off Service Notes
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Off-service notes
should be written for
complicated/chronic
patients, as well as
patients who have been
on the floor for more
than 3-4 days with no
discharge plans.
The off-service note is
a more comprehensive
SOAP note, including
problem list, brief HPI
and hospital course
since admission. Be
very detailed in physical
exam and
assessment/plan.
Running the List/Updates
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During the course of the day, update your senior (and
your patients/families) frequently.
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 Tip – Parents should not be asking the night team about
long-term plans! If they are, that is a clue that you should be
more on top of updating your families.
At 5pm, you should be prepared to give your senior
final updates for the day. This is key to leaving the
hospital on time.
Before evening sign-out at 6PM, you should have
obtained the most recent vitals for your patients and
have a good idea of what the night team should expect
overnight.
Medical Students & Teaching
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Medical students will be assigned to you when they come on
service. Typically, they will follow 2-4 of your patients during
the course of the week, after which they will follow a different
intern and a different student will follow you.
Med students should be seeing patients and writing notes. They
should also be presenting during work rounds and attending
rounds.
Be sure to take time to teach, even if it’s only pearls here and
there, or tips and tricks for internship.
Constructive criticism is especially important in history taking,
physical exam skills and note writing. Before co-signing medical
student notes, they should be reviewed and discussed.
PM Sign-Out
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Evening sign-out begins at 6PM in the 11N conference room.
Presentations to the night team should be brief, but they should
also include any and all pertinent information about your
patients that would be important to know overnight.
Report by systems, including your updated vitals.
Briefly list important medications.
Finish with a summary of night issues/things to look out for or
accomplish overnight, as well as labwork expected in the AM if
there is a value that needs to be watched for.
If necessary, also sign out if anyone needs to be called for a
specific parameter (ie, calling the endo fellow with urine ketones
and d-sticks at 10PM.)
Night Float
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The night intern rotation consists of two two-week blocks of
nights in which you will work Sunday through Thursday, 6pm
through 8am.
Your day will start with PM sign-out. Make sure to listen
carefully about anything pending overnight, taking notes on the
sign-out sheets if necessary. Both the floor team and heme/onc
will sign out to you, so it can seem like a lot. Feel free to ask for
clarification if something is unclear.
Depending on the night senior and number of pending
admissions, many night teams will do night rounds, which
consist mainly of introducing yourself to the patients and
families and asking if they have any problems or concerns.
For the rest of the night, your job is admissions. Have lots of
blank H&P forms and flow sheets readily available for use.
Night Float: Admissions
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Whenever your senior gets paged for an admission, ask him or her
to tell you about the patient, too. It’s nice to know what’s coming.
When a patient first comes up, grab the chart. Thumb through all
of the records already there, such as outside hospital or ED
records. You should have your HPI in chronologic order, and that
includes what was done for them before they got to the floor.
You will need a lot of stickers.
All PMDs need to be notified of admission, even if it’s 3am.
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Private attendings need to be spoken with in order to solidify plans for their
patients.
Pediatricians of service patients and surgical patients need to be notified but
not necessarily spoken to. Talk to their service and leave a message for the
morning. This is important because private attendings (especially of surgical
patients) will already be in the hospital to round in the morning and can
stop by to see those new admissions.
Night Float: Overnight
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Check vitals and labs frequently. If something looks suspicious
or impossible (respiratory rate of 0, for example), get
clarification! Make sure to have the nurses or CAs repeat any
abnormal looking vital signs.
If you are called to the bedside for whatever reason, write a 2-3
line event note in the chart stating why you were called, what
you did, and what the resolution of the event was.
Eat (deli opens at 12), sleep (seriously) and go to the bathroom
when you can.
Before signing out in the morning, get the vitals and labs on all
of your new admissions, listen to your respiratory kids and put all
your paperwork together.
Interns will start showing up around 6am. Update them on what
happened to their patients overnight.
Night Float: AM Sign-Out & Beyond
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AM sign-out begins with the night intern presenting new
patients. Presentations should consist of
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It will take awhile to finesse, but these presentations should only
be 2-3 minutes long.
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A brief HPI including what was done for them, if anything, at outside
hospitals, the ED, and on the floor
PMH pertinent to HPI
Significant labs/radiographs
Pertinent physical exam findings
Brief assessment/plan.
It is always good practice to ask for feedback from your seniors about
how your presentations are going and what you can do to improve.
After sign-out, the night team joins the day team on work
rounds. Monday through Thursday mornings, your day ends at
8PM. On Fridays, you should attend morning report.