My report....really is bad!

tboone246 · Mar 7, 2012

I work on on a med/surg unit that specializes in neurosurgery patients. We have "cheat sheets" that we report from, update them in pencil, and pass on to the next shift. It is a preprinted sheet with areas to fill in when the patient arrives. It follows the same pattern with each patient and helps you keep focused. It starts with the sticker from the pt. chart (name, age, admission date, and attending MD) and goes through everything in a simple format. It keeps you from rambling and most importantly keeps you from forgetting things. Most of us put our sheets in a folder with see through plastic tabs and keep them with us during our shift near our computers. I also use post-it notes to record any PRN meds I give pts so I can report that also. In addition I keep 1 piece of paper with info. from report that I write down to keep in my pocket at all times.

Esme12, ASN, BSN, RN · Mar 7, 2012

it is going to take time.......the first year, at least, you feel like a duck out of water. it will come...in time. your other post you were given an excellent cheat sheet ........you'll be fine.:hug:

day sheet 2 doc.doc‎(212.5 kb, 304 views)

dudette10, MSN, RN · Mar 7, 2012

Start making your report sheet as soon as YOU get report when you come on shift and fill it in with your assessments after you do them.

We have computer-generated SBARs that contain a lot of the information about the patient already, i.e. diagnosis at admission, attending, consults, code status, allergies, diet, PMHx, SMHx, abnormal labs w/in 24 hours, last 24 hours of output, and last 24 hours of VS. I jot down information from the off-going nurse assessment on the pre-printed SBAR.

I have my own custom-made brain sheet for my assessments and shift notes, kept in my binder so that the pages face each other (2-page spread for each patient). I don't make it a separate task to fill out my brain. I do it immediately after I assess--a minute, at most, per patient--and I make notes as things come up. A note might be, "0000, pain, lower back, 8/10, dilaudid; 0030 pain, 3/10." (These are just my memory-jogging notes to be used for report and to chart.)

Do a search here for "brain." You'll find many examples. Pick one that fits your needs and customize it, if necessary. Most nurses can't work without their brain sheet.

runner_rn · Mar 8, 2012

I could have written this post myself. I graduated in May 2011 also and started on a med surg floor at the end of november. Some days I feel like I do a pretty good job giving report, but others are just awful. I find the days I do better are when I have time to take a few minutes at the end of the shift and gather my thoughts, writing everything down that I need to report to the oncoming nurse, before giving report. I wish I had more advice, but I am struggling with the same problem.

NewGoalRN · Mar 8, 2012

Don't wait until end of shift to do it, u may run out of time and memory is not clear.

make it a practice to write donw notes on a cheat sheet as they occur or as u chart.

Start with the info you receive as you receive report. Usually hospitals have a summary sheet that you can print out with pt info, dx, meds, pertinent info, dr, TPN, rate, etc start witht hat sheet to ammend as you do your routines or use one of the sheets here.

U'll get it.

MamuhmiaRN · Mar 8, 2012

I know exactly what you mean! I graduated June 2011, and started on the floor in November 2011. We have to give a report to our clinical coordinator after the first few hours of our shift, and then again at the end of our shift to the oncoming nurses. I always think my reports aren't as thorough as they should be. It is hard to remember everything, so I do try to jot down any new info in a different colored ink on my report sheet to remind me of details to pass along. But I am a work in progress....some days I feel like it's coming together, and other days I feel like it's my first day again!

Just hang in there and keep plugging away....you're probably doing better than you think!

mom35 · Mar 9, 2012

Thanks all! I try all suggestions and just keep pushing through!

~PedsRN~, BSN, RN · Mar 11, 2012

Our floor has report sheets printed out for us to "fill in" - I will fill the sheet in as I am getting report, and then make notes on my care thru the shift on the same sheet with any major "updates". Last dose of pain meds, labs that need to be drawn, any new orders, etc. Anything that changes on my shift gets scribbled on to that report sheet.

Then I give my report from that sheet. :)

juana15 · Mar 25, 2015

Did it get better? I'm on the same boat you were on back then..... My notes are all over the place!! Help!!