Need Help With Blank Report Sheet!

Nurses General Nursing

Published

I just started working as an RN, and I am trying to find a blank change of shift report sheet to record the basic info about each patient I have on one paper, does anybody have a link or a saved document I could use. Thank you!

Up Vote Up Vote ×

Hi !

When I was a new grad (many, many ) years ago, one of the

experienced nurses on our floor had a great report sheet.

She used the kardex for the important categories.

It was something like this-

Name of patient--

Primary:

Surgeon:

Dx 1)

2)

3)

Surgeries:

Medications:

Iv:

Diet:

Treatments:

Pre op

post op

Labs-

(any other things you need to add for your specialty)

She repeated this about 4 times on a sheet

It gave us a nice format, I used it for years........

Good luck!

Up Vote Up Vote ×
Specializes in med/surg.

Do you not get a handover sheet? Or is this something you want as well as the sheet?

I'm in the UK & we have a handover sheet with all the basic info already printed out - usually a photocopy of the master made out by the nurse in charge of the late shift or night shift, plus the space for you to add your own comments. Once I know who my patients' are for the shift I just staple a blank sheet to the corner of the handover sheet & write anything extra or add as needed on that.

As I'm working towards coming to the US (N-CLEX on August 2nd - aurgh!) I'm always interested to see the differences there are.

Up Vote Up Vote ×

We use a kardex with the basic patient info on it, but I just want something I can copy onto one piece of paper so I can take it with me when I do assessments to make sure all of the information is correct. I was just wondering if anybody had made a sheet up so I could look at it to make sure I don't miss anything. Thank you for your replies!

Up Vote Up Vote ×
Specializes in Cardiac/Tele/Step-down.

I don't have a copy of mine to send ya. But I can tell ya what is on it. I made my own sheet on my computer at home.

RM#

NAME

AGE & SEX

DIAGNOSIS

DOCTOR

LAB- To check or needed to be done

IV- Where and when needed to be changed

FLUIDS - Rate and amount

DIET-NPO

O2- @____ or left blank or crossed out if not on any

PROCEDURES FOR TODAY

HISTORY

ALLERGIES-NKDA or _____

FOLEY (circled)

DRSG _____

BLOOD SUGAR AC and HS printed out and I would just circle it

DRAINS Where and circled type on my sheet

NOTES- Any extra stuff

Depending on your unit I pretyped some info on my sheets.So that way I could just circle it.

Like we had alot of PEG NG and JP tubes. So I printed them all on the sheet and circled the ones they had. Alot quicker since we take oral reports from prev. shift.

Hope this help.

Up Vote Up Vote ×
Specializes in Med-Surg, ER, TRAUMA!!.
Hey - just wanted to reply to your question: I am an RN from West Monroe, La. During my nsg career as an LPN, then as an RN, I have also utilized a second sheet to assist in my pt status, labs, or other pertinent information. I have a few "OCD traits" at times, and the example previously posted earlier would be a good "CYB", or help in remembering details noted that I had not written on my report sheet. This is very similar to one I use.Should help, if you're like me.
Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

I have a report sheet here

[ATTACH]5032[/ATTACH] (Report Sheet)

Please. . .feel free to download, copy and use it. I designed it to work for me. Maybe it's what you are looking for.

Up Vote Up Vote ×
Specializes in med/surg.
I have a report sheet here

[ATTACH]5032[/ATTACH] (Report Sheet)

Please. . .feel free to download, copy and use it. I designed it to work for me. Maybe it's what you are looking for.

This is a really neat sheet. I think I might swap my blank paper for a UK adapted version. Thanks!

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

You are welcome. I hope you find it helpful. It was created on Word using Table, so you should be able to change parts of it if you need to modify it. Turn on the gridlines so you can see how it is constructed.

Up Vote Up Vote ×
Specializes in Education, Acute, Med/Surg, Tele, etc.

That sheet is AWESOME! I added some things to circle at the bottom for my ortho and med surge pts like: foley, NG, HV (hemovac), JP, FD (flip/drip), CT and O2 orders. I also changed the IV space to include a circle for PICC, CL or P. And added one more space for PCA.

IT was so cool!!!!!! Thank you so very much!!!!!!!!! I really really really like this one!!!!!!

Up Vote Up Vote ×

I don't know how (or if I can) provide the link, but I posted the same sheet for someone on the nursing student board for General Student Discussion. Probably on the second or third page in by now. Look for a thread called Shift Worksheet; I posted it for gardenmum :)

Up Vote Up Vote ×
Specializes in 5 yrs OR, ASU Pre-Op 2 yr. ER.

Bumping, hoping for a sticky, since ther eare quite a few report sheet threads out there, and one big one would keep many together.

https://allnurses.com/forums/search.php?searchid=2290958

Up Vote Up Vote ×
+ Add a Comment