report sheets

Nurses General Nursing

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Hi all,

I am a new RN grad in my second week of orientation. I was wondering if any one could please give me good ideas on making my own report sheet with vital info on it. Any help would be appreciated.

Thanks,

sc:D

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Specializes in Cardiac Telemetry, ED.

What kind of floor do you work on? How many patients do you typically have? What sort of equipment, lab tests, procedures, dietary orders, activity levels, are routine for your floor?

I work on a cardiac tele floor with a typical patient load of four. My report sheet is a standard sized piece of paper divided into four quadrants. Each quadrant has a space for the patient's name, DOB, attending physician, code status, admitting diagnosis, and medical history at the top. On the left side of the quadrant is my assessment data section, and on the right is a vertical column divided into hours.

My assessment data section includes IVs (PIV, PICC, CVC), gtts, diet, activity level, then each major system (Neuro, CV, Resp, Integ, GI, GU, MS, Psych) and the typical things we see on our floor. For example, under the cardiovascular, I have "PP" for palpable pulses, "Edema", "Murmur", "Irreg.", and "Teds/SCDs". I circle or highlight the appropriate descriptors (if, for example, the patient has weak pedal pulses, I draw a small down pointing arrow next to "PP"). Under integumentary, I have "Inc." for incision, "wound", and "drain". If they have a pacemaker incision, for example, I circle or highlight "Inc.". If they have a groin puncture, I circle or highlight "wound", then to the right, write in "R groin".

Under the systems data is a space for my two sets of vitals, then under that is a list of common rhythms (NSR, SB, ST, Fib/Flutt, PVCs/PACs, Paced). Under that is the lab section, with a cross for Na, K, BUN, Cr, then an X for WBCs, H&H, and platelets. I have Trops, BNP, and D Dimer, since those are common labs for our floor and I can just fill in the value next to the word. I'll typically just write in the EF or any other pertinent labs/diagnostics in the leftover space. At the very bottom is a space for allergies.

For the time column, it's sectioned into hours. I use that column to note when meds are due, what the CBG results were, any tasks that need to be done at a certain time, and other information such as when the patient left and returned to the floor for a test. Any significant events, such as a run of PVCs or bigeminy, I'll also note in the time column until I have time to document the event in the electronic record. My pain assessments often go there as well, so I can write down the pain score and what meds were administered and when.

Anything that doesn't fit neatly into a category, I write in the extra spaces or along the margins of the paper. Sometimes, if I'm taking report from the ED or the cath lab, I'll write the report on the back of my sheet, since I never know what information they'll give and in what order, and I want to just jot it down quickly without having to hunt for the right spot on my brain sheet.

When I had preceptorship on a Med/Surg floor, my brain sheet was completely different. I didn't need a place for cardiac rhythms, the labs were different, and there was more emphasis on the GI and GU systems, so I had more options for bowel tones, abdominal distention, etc. under those categories. Since the diet sequence was fairly predictable (NPO, clears, full liquid, DAT), instead of having a space to write in the diet, I just had those categories on the sheet and would circle the appropriate one. Since NG tubes, PCAs/PCEAs, and TPN were pretty common, I had spaces for those things.

I've found that by having the most common assessment findings already printed on the brain sheet so you can just circle the appropriate one, but leaving a little space to the side to add a note, it saves a lot of time over writing everything out by hand. Again, those assessment findings are going to vary according to the area that you work in.

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Specializes in Orthopedics.

I work on an orthopedic floor so their are certain things we focus on when doing the assessment: bowel sounds, pedal pulses, whether the incision has steri-srips/staples and is it dry and intact etc, any drains, n/v etc.

I used to make a sheet for each person that had this information on it along with other info (PCA/Epidural, how high they could get their incenative spirometer, which arm the ID bands on, what their bowels and lungs sounded like, last BM, teds/scds on etc). Now that I have the hang of things and remember the important stuff that need to be documented I don't use that any more. I just jot notes down on my kardex for when I go to document things I can remember the patient.

Now that I feel comfortable on my documentation I made a sheet that has 5 columns with the times beside the columns that I put a check mark in so I know when to give meds. When I give pain medicine I write the medication given and the exact time (for instance beside the 900 column I'll write 15: 5mg roxicodone and in the 1000 column i'll write RA__ so I remember to reassess and document their pain). And at the bottom I have assess written and put a check mark beside it so I remember if I documented the assessment or not. I really like it! Keeps my organized. Here's kind of what my sheet looks like. I made it in a word documnet. (The star's mean meds are due)

Name/Rm # Name/Rm # Name/Rm #

0800 *

0900 *

1000 * * *

1100 30: 5 roxi

1200 30: RA__

1300

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

this is the one i used. feel free to download and use it.

[attach]5032[/attach]
my report sheet

here are others:

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this is the one i used. feel free to download and use it.

[attach]5032[/attach]
my report sheet

here are others:

thank you so much for those links; they're a great resource!

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