Re: Good Report Sheets
We 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.
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