Good Report Sheets
- 0Mar 9, '07 by nurse4theplanetBefore I spend hours in excel trying to design a good report sheet, I figured I would come here first to ask if anyone has one they would like to post.
Especially one that has a chart as well for vitals, hemodynamics, gtts, chest tubes, etc.
- 23,974 Visits
- 0Mar 12, '07 by nurse4theplanetshift to shift
Right now, I am just taking a blank sheet of paper and writing out several different headings...Neuro, Resp, Vent, Cardiac, GI/GU, Labs, Lines, Gtts, Misc...then I have to take another sheet out where I keep track of my q2h checks...vitals, BG, CVP, ICP, PA, CO, CI, SVO2, UOP, etc..whatever pertains to the pt.
By the end of the shift, its a mess. I have some from school, but they have way to much info that is not practical.
If anyone has a sheet that they use throughout their shift and for report that they would like to post, I would really appreciate it.Last edit by nurse4theplanet on Mar 12, '07
- 0Mar 12, '07 by incublissRNI have a nice sheet at work that we all use. Let me grab an extra copy when I work on Thursday night and I'll scan it and post it. It might be helpful. It's tailored towards surgery patients since I work in a cardiovascular thoracic recovery unit but maybe you could adjust it to work for you.
- 0Mar 13, '07 by cvicugirlWe have a thing called an "active intervention" that we print out at the beginning of the shift. The first page contains pt name/ht/wt/age/allergy/ initial diagnosis/active docs on their case. The next few pages contain all current active orders and medication orders and scheduled administration times. I always attach it to the patient's clipboard along with their VS/assessment graphic, blood glucose flowsheet, rhythm strip documentation page, and daily lab results. When I take shift report, I write it on the first page of the active intervention or a blank sheet of paper. I like to take and give report by systems, so I'll write: cardiac, resp, GI, GU, neuro/comfort, skin/wound, and family, leaving space to write underneath each heading. I have always done this, and it makes it easy to take report from the nurses who bounce all over the place when giving report. (UGH!)Under cardiac I'll note last shift's rhythm, rate, average BP, Tmax, lines, and current drips. Under resp I'll note O2 flow rate, any difficulties from previous shift. For GI/GI: diet, NPO status, blood sugar frequency, urine output, foley. For neuro/comfort: A+Ox3?, last pain med, activity. For skin/wound: location, description, dressings, chest tubes. Family: visitors, problem visitors, anything I need to tell case managers, discharge stuff. After report I'll go through and highlight my "task times" --things that need to be done at a specific time, like meds and blood sugars. I keep this 1st page with me throughout the day. If anything changes, I'll add to it under the appropriate heading in a different color of ink. I use the same sheet when I report off.
It is important to figure out a system that works for you and then stick with it. And you don't have to write every single thing down during shift report. I'd eliminate writing VS/swan numbers and stuff on your report sheet--you'll drive yourself crazy. When you do them, chart them where they need to be charted and be done with it. With experience, you'll learn to streamline!
Good luck, I hope this helped.
- 0Mar 13, '07 by nurse4theplanetQuote from incublissRNThat would be great. Thanks!I have a nice sheet at work that we all use. Let me grab an extra copy when I work on Thursday night and I'll scan it and post it. It might be helpful. It's tailored towards surgery patients since I work in a cardiovascular thoracic recovery unit but maybe you could adjust it to work for you.
- 0Mar 13, '07 by nurse4theplanetQuote from cvicugirlI don't write them on my shift report. I keep a separate sheet of paper. We do computer charting so when I chart the numbers in the computer...I still like to have a paper reference to look at when I get an unexpected question from the doc, etc. while I am away from the computer. Since I am a new grad, it helps to keep a close eye on trends and my thought processes are not quite as quick as an experienced nurse.I'd eliminate writing VS/swan numbers and stuff on your report sheet--you'll drive yourself crazy. When you do them, chart them where they need to be charted and be done with it. With experience, you'll learn to streamline!
Good luck, I hope this helped.
Ideally, I am looking for a setup that has a report sheet on half the side and a grid for VS/hemodynamics on the other half...that way when you print it out on a standard 8 1/2 x 11 sheet of paper, you can just fold it in half and have your report on one side and your daily values/measurements on the other for quick reference. And then I will only be carrying two sheets of paper in my pocket instead of four or more.