Off the top of my head for med/surg tele, this is my order:
Name/ doctor/ age
Most important thing about this patient
New orders this shift/ day
Head to toe including: orientation, edema, pulses, tele, breath sounds, heart sounds, surgical incisions, chest tubes, jps, pacer wires, abd quality, abd sounds, bm and voiding issues, heplock info and date, ivf, pca and pain meds, level of dependence, abn vital signs, abn labs.
I try to check all of my charts before I go into report so that I know what I'm talking about. However, I sometimes get in there and don't know something and have to apologize on tape.
At least I'm amusing.
Just tonight I couldn't remember if one of my seven had a foley in. Gee, I felt like a HUGE idiot over that one, but I found out and clarified in updates.
I'm much, much, much better than I used to be, though.