Work Sheets and Getting Report

  1. Hi,
    I am a new grad and a new nurse I need help finding a worksheet that will help me quickly and accurately take report. I have tried making my own but have been unsuccessful. Can anybody help? My email address is danielbow@earthlink.net
    thanks
    •  
  2. 23 Comments

  3. by   timonrn
    A report sheet is a very personal tool that is all your own. We have "brain sheets" that are generic and each nurse uses it to their taste. I also work with newer nurses who have their own individual sheets. My sugg. to you is work w/ what your unit has--what makes you feel comfortable and what you feel you need to know. Trust me--in two years your brain sheet will have hardly anything on it!! Also, keep trying to make your own personal sheet--leave it on your computer and re-work it until it is what you want--there is no "perfect" prototype that I know of. (one of our last projects in school was the perfect report sheet--we actually got graded on this)!!
  4. by   plumrn
    If you have computer charting or computer generated kardexes you can run a copy of your pts kardexes,staple them together and use a highlighter for important info.such as allergies,IV fluids,labs due,etc..Take report in 1 color ink and write your shift assessment,vs's, etc in another color.You have everything you need right there with you at all times.(These also have all the meds listed.)Add new orders to your kardex copy as you go and its a breeze to give report from.It's more difficult if you're in charge though because its just too much paper to carry with you.Hope you find this helpful.
  5. by   lv2ski
    You eventually develop your own routine. I automatically place stuff in a certain order on my little sheet, with lines dividing ea. pt. I also use a multi-color pen. red for important stuff i.e. allergies, code status....green for stuff I've done and need to chart.....it helps alot. good luck.
  6. by   acarlrn
    hi, I am interested in the response from plumrn. I too work at a hospital that has computerized charting format. I am interested in discussing the pros and cons of computerized charting with you if you read let me know if you would be interested in this dicussion.
  7. by   OhioCAPDNurse
    Glad you asked this question!!!! Recently on another nursing board, I asked the other nurses to email me a copy of the brain papers they use at work. Only got a few responses, but have a collection of about 4 or so. SO If you all would be so kind, email me a copy of yours, I will make a collection, and email copies to whoever would like them. Or if you would like what I already have, let me know. Please send your Brains to Chell1976@aol.com
  8. by   rebelwaclause
    dbow...You've got mail at earthlink.com
    OhioCAPDNurse,...You've got mail at aol.com
  9. by   debRNo1
    I just started on a med surg unit and these "reports' are an issue for me, coming from LTC Im not used to this.......

    I didnt care much for the ones they use- just too busy for me with alot of nonsense space. One nurse had one that fit all pts on one sheet-tried it-just too cramped for me. I kinda played around and made my own but had trouble doing it/fitting it on the computer so I just played with it (cutting and pasting like I was in kindergarten!) till I liked it and made a bunch of copies. Guess it is an individual thing and I use the colored pens and "checkoff" boxes for things I need to do. Its good when charting time comes because its all there and I wont forget to write something
    (I hope)

    Usually have 6-8 pts and I can fit 3 on one sheet. Rm/name/age/dx/loc/diet/activity/MD
    IV site/date/solution/rate
    checkoff box for meds (with the times) PO or IV/ABT/PRN/pain
    skin/lab/tests/PT/other (left some room to write whatever....)

    last I have a checkoff list to make sure Ive done it all.
    assessments/meds/notes/orders

    Used it yesterday for the first time and it worked well.

    But Id be interested in what everybody else is using, cant email mine its on real paper-could fax it I guess ???

    deb

    Michelle please send me the ones you have.......

    debRNo1@aol.com TY
  10. by   NS_RN
    For some unbeknownst reason to me, the bullies on my floor insist that we take report on all 34 patients!!! Drives me nuts. Even though I am assigned to only my bunch I hafta sit thru a lengthy taped report on all 34. Anyhooooo, I digress.
    Our report sheet is a long piece of paper with just the room numbers on them. Thats it. A blank space by each room number, so you can write in your own info.
    Last edit by NS_RN on Jan 24, '03
  11. by   meownsmile
    I do a senerio similar to plumRN. Take report in one color, write new orders and things to give in report in another. I make 3 columns on our computerized Kardexs and use the first one for recieving report(usually in red), middle for patient changes or new orders during shift,, and 3rd for anything i need to tell next shift coming on(in black)last vitals, last pain meds, I/O, etc. So i basically give report off of the 2nd and 3rd column. If there is anything from AM report that i need to pass along i usually star it or circle it in black. I usually try to keep it short sweet, i dont go into the breath sounds etc., only if there has been a cardiac change or an extreme change in a system on that shift.
  12. by   deespoohbear
    [QUOTE]Originally posted by NS_RN
    [B]For some unbeknownst reason to me, the bullies on my floor insist that we take report on all 34 patients!!! Drives me nuts. Even though I am assigned to only my bunch I hafta sit thru a lengthy taped report on all 34. Anyhooooo, I digress.


    My guess is that will come to a screeching halt once the "lovely" HIPAA laws come into effect on April 14....you don't need report on all 34 patients on your unit to do your job...just your assigned group....talk to your privacy officer...
  13. by   Flynurse
    Could someone send me there brains to me too!?

    I recently started at a hospital and am having a hard time trying to figure out how to make the assignment print outs work for me. They only take up half the sheet for 6 pts. I need some ideas!

    email: Flynurse@optonline.net

    Thank you in advance.
  14. by   flashpoint
    We take report on all 22 patients on the floor. It gives us at least a general idea of what is going on with everyone so we can answer call lights and things without looking like we don't know beans about the patient. We also like to know what's going on with everyone so if a nurse gets pulled to another area for a while we can cover and so we can cover each other on breaks. Our "brain" has four columns...the first has the patient's name, age, doctor, and diagnosis. The second is blank for whatever we feel the need to write. The third is for orders...meds, nebs, glucs, etc...the fourth I use for everything I need to report to the oncoming shift. Some of the nurses use their own "brains" but I've found that this one works well for me. Sometimes, I'll grab an extra one if I have a lot to do for a patient.

close