[ariesbaby]

Hello -
I am a new nurse working on a nephrology/urology floor, but we have 6 beds set up for telemetry too. I'm looking for samples of shift report sheets to keep track of my patient's vital signs, labs, I/O etc... I've spent hours making one on my own but it doesn't work for me. Nurses on my unit on days are assigned 4 patients (sometimes 5). I had originally hoped to make a sheet that I could put all my info on for all 4 patients, but I can't write that small I discovered! I'm deciding I might just have to suck it up and carry a 3 ring binder around with me - I hate carrying anything other than what fits in my pockets though because I lose track of stuff so easily! Anyone have any suggestions and examples of shift reports that they could share with me? I would greatly appreciate it!!!!

Thanks!

[AfloydRN]

When taking report from outgoing shift, write down all pertinent info in sentence form. This may seem retarded but has worked for me for 11 years. No special form to fill in the blanks. Just patient name, dx, MD, and basically what we are doing for him. Fold it up and put it in your pocket. Nothing to carry around.

[AtlantaRN]

I've worked on a med/surg floor and the stepdown unit, and this is what works for me. I use a clipboard for each patient, it has my patient profiles (kardex), MAR's, and even though everyone is trying to go paperless, I always print the labs....

When I have time, I write down on a plain piece of paper:



name dob
docs/consults
admitting dx:
Presenting complaints:

history: just a synopsis...

N= Neuro

C=Cardiac--heart sounds, rhythm, rate; any dependent edema.....

P=Pulmonary

GI

GU

skin

New Treatments:

New Meds:

Concerns:

Lab Orders Pending:



then I just jot next to each one, that way when I give report, even if it's
been a crap day, I can have my thoughts in order because face it; some days everyone starts looking the same.....

I know we are all going paperless, but it works for me.

I've never had anyone complain about my reports....and if someone just wants to know the updates, i'll just read them that, and let them have my sheet if they want it.....

[irish_std/n]

we get report on 13 pts, I use a plain A4 sheet folded in half lenghways, the fit 6 pts on one side and 7 on the other, just name, age, doc, diagnosis, relevant hx, jobs I have to do and any outstanding tests with a little checkbox next to each that can be ticked when same is carried out, its amazing how much you can fit on one little sheet to carry around in your pocket.

[Daytonite]

I know this is an older thread, but this is a subject that comes up a lot, so I often post a link to my report sheet which has been on file with the forum for a while. You are all free to download and use it.

Attachment 5032 report sheet