anyone have a good sheet for taking report on pts ?

Specialties Ob/Gyn

Published

I was wondering if anyone is willing to share their sheet for taking report on mother/baby pts. I'm struggling w/ keeping everything organized on my paper. It's hard for me to see what I need to do next such as what labs need to be drawn, when to do the PKU, when to do the TCB... maybe this will just come quicker w/ time but I'm wondering if I'd be faster w/ determining these things if my sheet looked more organized. Any suggestions? Thanks in advance!! :heartbeat

:) hi there~

i have several that i have collected since my externship, internship, and some very recently. although none of these are in file format to upload, i can try and get them scanned somehow (i don't where i would go to do that), or i can fax them to you somehow if you are able to be somewhere where you can receive faxes. i am working saturday, so i can for sure fax them to you then. let me know, and if you want me to, then pm with your fax number and who to attention it to. i have at least 5-10 different ones so i would love to send them to you.

let me know!

take care,

jadu1106

Specializes in ICU/Critical Care.

I gave up on those sheets. I tried. The other day my report consisted of..."This patient was shot in the head. He is gift of life"

Specializes in ICU.

namediagnosisneuroCVrespGIrenallabsJoe Smith 54 Med A full code Afib RVR, hx: MI, CHF renal insuff. A&O x3 mae = obeysAF ~100 +1 edema, PP+50% sats 92, crackles SOB exert BS+ tol. Diet, cardiacfoley u/o ~ 40/hr, clearaccu-checks 8, 12, CBC, BMP06 12

it's centered on the sheet. i use the space left on the left for events of the night, the space on the right for new orders of the day........hope it helps, easy to do on an excel spreadsheet :heartbeat:heartbeat:heartbeat

Specializes in ER.
namediagnosisneuroCVrespGIrenallabsJoe Smith 54 Med A full code Afib RVR, hx: MI, CHF renal insuff. A&O x3 mae = obeysAF ~100 +1 edema, PP+50% sats 92, crackles SOB exert BS+ tol. Diet, cardiacfoley u/o ~ 40/hr, clearaccu-checks 8, 12, CBC, BMP06 12

it's centered on the sheet. i use the space left on the left for events of the night, the space on the right for new orders of the day........hope it helps, easy to do on an excel spreadsheet :heartbeat:heartbeat:heartbeat

there's nowhere to submit an attachment, I have a document you might like...

Specializes in ICU.

sorry kids that just came out waaaaay wrong.....lol

Specializes in ER.
sorry kids that just came out waaaaay wrong.....lol

:confused: ??

Specializes in med/surg, telemetry, IV therapy, mgmt.

early in my career i made a flow sheet to remind me what to do when patients had chest pain. it included my facility's chest pain protocol. i typed it (no personal computers in those days) and wrapped it in clear contac paper to strengthen and protect it. i still have it. today there is a similar type of thing called clinical pathways designed for patient problems. they are basically canned careplans that have assessment and nursing interventions listed in a day-by-day, step-by-step format. some facilities use these and swear by them. maybe someone reading this uses clinical pathways for ob where they work and will respond to this thread.

otherwise, in today's world a work sheet can be created for yourself on the computer using your word program rather easily. i always used table commands for this because it creates nice boxes (the program refers to them as cells) for you that you can type in. this is what my last report sheet that i used looks like: [attach]5032[/attach]. feel free to download, copy and edit it in any way that it will work for you. if you do not know how, pm me and i can customize it for you. as you might be able to tell i was a med/surg nurse. most of what was typed on the top margin was removed in order to post it here because it had all kinds of extension numbers on it so i had them at my fingertips. i also needed the day and date there because i could never remember them. but, that's the advantage of creating your own tool.

here are links to other report sheets that you can look at, get ideas from and/or download and copy:

Specializes in OBGYN, Neonatal.

I'm going to try to see if I can explain mine b/c I do it by hand in the morning b/c I always forget to make one and print it out LOL I need to start doing that though.

Anyway, I take one piece of regular printer paper and fold it into fours. Then straighten it back out again. Then each square is for a couplet and I use the back too b/c most of the time we have 5 couplets or more. In the square I put at the top, mom's last name and room number and what day she is (i.e. is she a post partum day one or a c-section day one, etc) and her ob's name. I put moms' information in the majority of the box and baby's in a smaller poart of the box. I have a space for v(void) s(stool) p(pku) c(circ) and a check line to remind me when I've assessed the baby. Also I note whether its breast or bottle fed and who its pediatrician is.

In mom's box I put vitals, and meds and such to keep me on track.

I know this is hard to picture, I'll have to find the one I did do on computer somewhere and see if I can attach it. The ones I do by hand are easier for me but I will try to start using computer ones to save a few mins!

Specializes in OBGYN, Neonatal.

Ok I found said worksheet LOL but its in excel. How do I upload an attachment here?

Specializes in OBGYN, Neonatal.

nope can't load still sorry! will keep trying!

Specializes in OBGYN, Neonatal.

Never mind guys sorry! It was the wrong thing LOL, I'm scatterbrained tonight!

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