Does anyone have a good report sheet?

SoundofMusic · May 9, 2008

I have one that I am fine tuning and experimenting with. I will post it when I feel it's ready.

You can do a search here on "shift report forms" and get a lot of good examples of what people are using. It wll be a start and perhaps you can design your own.

I used mine for the first time yesterday and now I'm ready to fine tune it. But it really helped me to stay on track just a bit better. I'm still working out my own system.

racing-mom4, BSN, RN · May 9, 2008

I have one that I am fine tuning and experimenting with. I will post it when I feel it's ready.
You can do a search here on "shift report forms" and get a lot of good examples of what people are using. It wll be a start and perhaps you can design your own.
I used mine for the first time yesterday and now I'm ready to fine tune it. But it really helped me to stay on track just a bit better. I'm still working out my own system.

I would love to see it when your done---I had my review last week and was told the only suggestions I received on my peer review was my on my report.

imanedrn · May 10, 2008

PM me with you e-mail address, and I'll send you mine.

cpnegrad07 · May 10, 2008

I will attach mine and paste it here. hope one comes thru:

name

PAIN_______________________

PAIN MEDS:_____________________

NEURO: O x______

RESP:______________O2?____Sats:_____L:____

LungSounds:_________________

ChestTubes:__________________

C/V:Rhythm____________Rate__

I/Vs________________________

I/Vmeds_____________________

GI:_________________________

LBM_______ NPO?____Diabetic?___

B/S________________________

GU:________________________

BRP?____Foley____

SKIN:_______________________

Turn?_______________________

Ambulation?_________________

Ted/Scd_____________________

LABS________________________

Procedures___________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Shift Report.doc

imanedrn · May 10, 2008

The first page is my primary report sheet / brain. Assessment data goes on the RIGHT. I list what the night shift tells me in green and add my own notes in blue. On the LEFT, I circle med time in red, cross them off in blue (as I given them), write down abnormal labs, and write my plan of care / what needs to be done along the day (i.e., dressing changes that are known at the start of the shift and any new items that come up (i.e., procedures) throughout the day).

The second page I use for vitals and misc notes, i.e., if I don't have time to chart that patient left for CT at 1005, I write it on this sheet, then chart it later.

Do what you like with it. Let me know if you make any changes that you find useable/valuable because I'm always looking for improvements.

08-03-09_NurseAssess_Individual.doc

A_Simp · May 20, 2008

I have a Report sheet that the RNs in my unit use. I used it during my clinical rotations. It is a MS Excel spreadsheet. PM me and I'll send it to you.

TX_TeleRN · May 23, 2008

I don't know how to attach my file, but I use two forms that I made to help keep me organized during my shift. It's in MS Excel. If interested, PM me and I'll send it to you via e-mail.

The first form is a table/grid that I can organize my tasks for each patient. I take about 10 min to fill this out as I review charts/orders after getting report at start of my shift. Above RM/Name, I write my codes: iso (isolation), DNR, TC (total care), ... In the time boxes, I write meds, dsg chg, called doc, etc., to keep me organized and help me remember what to chart later. At the bottom blank spaces, I write key things only, IVF/rate, Foley, PICC, daily wgt, samples to collect for lab, procedures for the day,

The second form is my report sheet. I work on a telemetry unit so I change it to what I need most on my unit. I reuse this form while pt is on unit and try to only discard it after pt transfers out or discharges. I found that I was "hunting" too much when I made my form as a checklist, so I allowed more space to write in. I use chart label at Rm#/Name and add additional doctors' names below it. I write up-coming orders/procedures/labs, etc. at bottom white space. I use different colors for each day I provide care. It works for me. If it works for you, great!; If not, I tried. :clown: