assessment sheet or report sheet

PinkNBlue, BSN, RN · Dec 3, 2008

I posted this in another post similar to this. I'm not sure if this is what you're looking for but maybe it'll give you ideas. :)

Our report sheet is made in excel. It is on a long horizontal sheet of paper with 23 horizontal rows. It starts with patient's 1) room number, 2) age of the patient, then the 3)name, the type of delivery (PC/S, RC/S, VAG), the date and time. Then the 4) doctor, 5) Allergies and hx 6) G/P 7) Discharge date, 8)Diet, 9) Whether or not she is voiding (V), has a foley (F) or if an antepartum has BRP, 10) Epis and degree of tear, if any 11) IV, 12) Mom notes (last time she had her meds, if she's on any abx, edema, c/o anything in specific etc), 13) Mom's blood type and rubella status, 14) Whether mom is breast or bottle feeding, 15) Baby notes (blood type if drawn), or any issues with baby or if baby is in NICU, 16) 24 hour Bili results, 17) GBS status of mom, 18) results of septic w/u on baby, if drawn, 19) Hep B (if it's needed/been given or if parents refused), 20) hearing test done or needed, 21) Gender and weight of baby, 22) Circ needed/no circ, 23) Pediatrician and security band #.

The nurses will then fold the sheet in half after getting report and write their own notes but the backbone of the report sheet helps a lot to know the basics of the patient. It gets printed about 2 hours before the incoming shift so the current nurses can update on their patients, if need be, or patients are deleted if d/c'd. HTHs a little.

Race Mom, ASN, RN · Dec 5, 2008

I just tweeked this one to fit the unit I'm on. We are a smaller unit, we do rooming in, but not couplet care. We also have gyn surgery pts. There are two report sheets on each page, you just cut down the middle.

Brain.doc

PinkNBlue, BSN, RN · Dec 6, 2008

I just tweeked this one to fit the unit I'm on. We are a smaller unit, we do rooming in, but not couplet care. We also have gyn surgery pts. There are two report sheets on each page, you just cut down the middle.

That's a cool report sheet! I like it. I usually end up writing the things in the baby note's part (like baby's blood type/coombs pos or neg, the 24 h bili result etc) so to just have a spot for it is really nice. Plus knowing the time of the PKU/BILI is awesome too. Our nursery nurse handles that normally but it's still nice to have that knowledge (we do couplet care). Thanks for sharing that :)

Race Mom, ASN, RN · Dec 6, 2008

Also, when I take report, I take it with a blue pen. That way I don't get mixed up on my info and older/shift change info.