Need end-of-shift report sheet!

[sonja77]

I work on a med/tele floor and here's the one I use. you would just need to modify it for certain common procedures/circumstances happening at your floor.

I have e.g. hd/pd (hemodialysis/peritoneal dialysis) since we have quite a few renal pts. on dialysis, or tele since we have a lot of people on telemetry.

report sheet (2 pt.).doc

[Florence NightinFAIL, BSN, RN]

Date _____ (important, countless times wrote wrong date on charts lol)

Name ______ Age ____ Sex _____ Code Status _____ Allergy _____ Dr _____ Admission date ______

Diagnosis _____ Surgery & date _______ Post Op day #________

IV/SL product, location, rate ________

Tubes & Drains ________(Foley, NG, Chest tube, etc.)

Diet________

Activity __________

Pain __________

Abnormal assessment _____________

Labs ______________

Tests _______________

Previous shift report ________________

At the end I would write down times I would have to complete tasks then cross out as I complete them, for example:

Vitals: 08 12 16

Gluc: 07 12 15

Meds: 08 10 16

In/Out: 12 18

Dressing change: 10 14

Charting: 10 14 18 (this helps me remember to check my charting)

those are the main points -- the rest of my sheet is specific to each pt.

Hope this helps. I know that the days I use this my time is managed much more efficiently and I'm less likely to panic and run around like a nut.

[Daytonite, BSN, RN]

This is the one I use. Feel free to download and use it.

Report Sheet (1).doc

[Jennerizer, ASN, RN]

I work on a tele/PCU floor & tend to work 3 shifts in a row...so mine is a bit longer & more detailed so I can just add on updates each day.

JREPORTSHEET3.doc

[mydesygn]

ilabooshka said:

Hi there! I am a new RN, starting out in med-surg. Does anyone have any report sheets or patient organization sheets that you could pass on to me? Any help would be greatly appreciated, as I am still trying to figure out what works for me...

This is the Jot that I have used (that I take report on for my shift). It has room for 5 patients. I write my meds/treatments/feeds into the time blocks (obviously I worked nights) and I write the report I recd into the block marked report. I ususally use the notes section for something I want to remeber to say in off-going report. It is set up to be printed on 11X14 instead of standard paper but I bought a package of colored 11X14 paper which works great because I can easily find my "jot" if I left it in a room.

Are you also looking for a sheet for reporting off? Do you do a written report at change of shift.

Jot.doc

[Indy, LPN, LVN]

mydesygn said:

This is the Jot that I have used (that I take report on for my shift). It has room for 5 patients. I write my meds/treatments/feeds into the time blocks (obviously I worked nights) and I write the report I recd into the block marked report. I ususally use the notes section for something I want to remeber to say in off-going report. It is set up to be printed on 11X14 instead of standard paper but I bought a package of colored 11X14 paper which works great because I can easily find my "jot" if I left it in a room.

Are you also looking for a sheet for reporting off? Do you do a written report at change of shift.

I really like yours for a time organizer! I can see where under 2000 block you might write assessment notes... VS under the blocks where you do VS, etc. OR you can fold it in half, crease on the short side, and on the back have lines horizontally that line up with the front side, and more notes there if needed. Very nice.

I don't think of the report sheet as a "end of shift" thing. Ideally it should be a brain! The thing you carry all shift, could chart from if you need to, and is organized in such a way so that if you read from it after 10 hours of running, it'll make sense to the next shift!

I have not done the premium thing. I'll list here roughly what goes on mine, as there are several word documents I have that have the same stuff on it, some in columns, some in 4 squares on a page, etc. Different strokes for ... you know.

I put a patient sticker at top. (So it has to go in the shredder at the end of the week. )

Room No.

Name Dr.

Dx.

Lungs:

Cough:

Edema:

Pulses:

Abd: (abdomen, including bowel sounds, last BM)

Diet:

INT:

IVFluid: (I don't write the IV stuff in till I see the patient. So it's accurate no matter what I get in report.)

Skin:

(I know I left out neuro. I work in tele; I'll scribble on back if neuro problems come up.)

Tele: O2:

Tele: O2:

Tele: O2:

8VS:

12VS:

4VS:

Meds: Labs:

--------------------------

Procedures:

------------------------

Wt:

Intake: Output:

------------------------

My favorite form of this is in four columns landscape (sideways) on a page, to fit a clipboard. My use of it is, that I highlight things I need and cross out things I don't. Highlight weight if they need a weight. If I admit at 0300 cross out other two VS lines. Cross through tele if they don't have telemetry. Write reminders for odd times of meds, but not the meds themselves. I can fold it over along the column lines as needed to scribble on the back or to add a 5th patient. There's a maybe one inch width blank space up and down the column where I scribble the times I was in the patient's room and my own unreadable abbreviations for what I did or found. Helps with charting and if I need to suddenly tell someone what's up with the patient right in the middle of something else.

[JentheRN05, RN]

Here's mine Hope it helps

Report sheet (1).doc

[lonestar88]

This is a report sheet I use at the PICU which I'm sure can easily be used with the NICU as well

Report_sheet[1].doc

[MrsMommaRN]

What an awesome work up sheet. I love it. I am saving it and taking it with me to med surg clinicals. thanks from a nursing student!

[ilabooshka]

Wow, thanks so much! I will try these out. :)

[caba35]

Thanks, very helpful

[NotAboutMe]

Thanks A Bunch !!!!