Need help creating a report sheet

babynurselsa, RN · Aug 19, 2005

What has always worked well for me is a sheet marked off in 12 hr blocks. YOu should have a line for each pt.

So say you have VS due on baby #1 at 1900 mark vs in that block. Then you have a caffeine due at 2100 so mark that in that box. Get the idea?

Then as you complete each duty you can draw a line through the box so you know it was done.

Hope this helps.

nursefreak1 · Aug 19, 2005

[NICU nurse2b,

where are you in school? I'm in michigan too and will be doing mother baby im about 10 days

leepgirl · Aug 19, 2005

Hi, I am a new grad in the NICU and initially found this to be difficult also, so I created my own, I'd be happy to email to you if you'd like. My report sheet if 1/2 sheet sized has fill in for most basic information such as age, weight, as well as O2 (included route, rate etc) and nutrition (w/ type, route areas to fill in such as OG ___fr. taped at _____cm @_____, residual______). I made a 12 hour grid to write in med/procedure times included a place for note and seperate section for data I want to make sure to include when giving report to the next shift. This has worked very well for me and even some of the more seasoned nurses have asked for copies.

Daytonite, BSN, RN · Aug 19, 2005

I always created my own report sheets. With computers it's easy to create a report sheet using the Table program in MS Word to my exact needs. Each cell of the table was set up like this: At top left I put the patients last name, first name, age and doctor. On a second line below that I listed the diagnosis. Then I started listing in a concise, brief form the important doctors orders that had to be followed and carried out. On the right side I made room for V.S., blood sugars, things like ABGs that I had to know (or perform) during the shift along with the times they were due. I would draw a line next to them so I could easily jot down those results when I obtained them. At the bottom of each patient's block (or cell) I listed labwork, x-rays or other tests that were going to be done that day. I also used to highlight those in yellow to draw my attention to them at a glance. If a patient was NPO I wrote that in large block letters with red ink in the section of the cell that was just below the doctor's name. The center of these blocks (or cells) is where I jotted down information about the patient that I got in report. I used different colors because I'm just a color person. I almost always took shift report information in red ink but sometimes I used a tourquise colored ink pen. On the back of my report sheet I used to jot down my IV meds and the times they were due. However, since you are a student you can just jot down the meds you are to give the patient and the time they're due. You'll need this information if you have to turn in a care plan on the patient later on. Do not make the mistake of giving medications from any list you generate. Give medications from what is on the medication sheet. I always liked to make a list of my IV's (patient, room, fluid hanging, rate) because it was just easier to see at a glance what I had going in IVs. I liked to make a notation for tube feedings due in a patient's cell by listing the time and then X-ing off the time as I did the tube feeding.

For one nursing home I worked in, I was assigned to the MediCare hall. The patients didn't change much (at least not as rapidly as in the acute hospital). I created a table program that I saved in a file and kept on my desktop so I could access it rapidly. I typed into each cell information so I didn't have to write it all down again every day. It was easy to open up the file, make any changes to it and then print my report sheet for my next shift. At the very top of this sheet I printed out the day of the week and the date usually in 16 or 20 point type (one less thing to have to think about!). I also had key phone numbers up there at the top (pharmacy, PT, DONs cell phone) so I wouldn't have to look them up. You see, the more I had written down, the less I had to worry about wasting time to find this information. I also tweaked and changed the overall set up of the sheet sometimes because I found that something just wasn't working well and I needed to change the sheet to be a more helpful tool for me. Over time I got really, really good at using all the features in Table. You can do some awesome stuff with it.

I also, saved all my report sheets for long periods of time. Those sheets had vital signs and blood sugars on them as well as notes I had jotted down when talking with doctor's on the phone. Sometimes referring back to them was a real help. When you write something down you don't have to worry about memorizing it. Just look at your sheet. God help you if you lose the sheet!

Just a little insider info. . .we called these report sheets our "poop sheet" or

"our brains". Hope this gives you an idea of a direction to go with this.

prmenrs, RN · Aug 20, 2005

I made one several years ago. It turns out to be 8x 5 1/2, two-sided. On the back of the page, draw a line vertically down the middle. On the left side goes the babies hx: DOB, gest age, birth wt, Apgars, and initial dx. Since a lot of these are the same, I pre-printed them, using acronyms: RDS, tachyp, GRF, IDM, pnm = pneumonia, pntx = pneumthorax, NEC, IVH gr________, Heart________etc. On the right side is mom's hx: age, G/P, vag, assisted delivery, C-Sect. PROM, Diabetic, NO PNC, PIH, Drugs. Further down on her side was Social issues, D/C teaching needs. The reason you pre-print all this stuff is so when you get report, you can just circle stuff or fill in the blanks.

The front of the form is also divided vertically, but with a space @ the top for name today's date, today's wt, and wt change from yesterday. The right side of the front is your time schedule like was previously described, w/ meds and feedings placed @ the scheduled times. You can cross them off as you go, you can use the box to scribble VS, in and outs before you transfer to the chart. The left side gets divided into boxes: Pulmonary, IV's, labs, feedings, and a 'leftover' box. I actually cut out the box on our charts we used record vent settings; leave space for the most recent blood gas. IV box should be big enough for Hyperal, lipids, assorted drips and pressors--whatever. Labs--put values from report, any scheduled lab draws can go there or in the timed side. Feedings: what, how, when. Leftover--if pt has chest tubes, surgical drains or anything else that you need to write down.

Last but not least: shred this document @ the end of the shift, and keep it in your pocket during the shift so only you have access to the info. YOu will also find that report off is much easier w/a report/work sheet.

Good Luck!!!

Gompers, BSN, RN · Aug 20, 2005

We don't need report sheets anymore where I work - everything is on the computer now, and each shift we print out a patient care summary. On this, there is a place for us to type in each baby's history (and we can change and update this as often as we want) so it's all right there in front of us when it comes time to give report. Besides the baby's history, this summary also lists every current and upcoming physician order. Usually, if it's important enough to report off to the next shift, the information will be on this sheet. Between that, our computerized MARs, and our flowsheets - it's all right there, organized. It makes giving report so easy.

What cracks me up is that it's all there, in black and white - yet some nurses feel the need to write this all down while we give report! I mean, if there's a social situation going on of course we don't put that into the computer, we just pass it along verbally - this stuff we might jot down by hand. But I don't mean that stuff, I mean things that are already IN the summary - they see it typed all up, nice and neat, and they STILL copy it down (often verbatum) for themselves. :confused:

As far as keeping myelf organized...I use the "company stationary" - better known as paper towels. I just put the baby's name at the top, list each hour of the shift down the left side, and then write everything on that - what time vitals, feedings, medications, treatments, labs, etc. are needed. Just clip it to the bedside clipboard, and cross things off as I go along.

ETA: To make your own organized report sheet, just keep it as simple as possible: column or boxes for each thing (history, orders for things like vital signs, feeds, I&O's, meds, respiratory care, labs, etc.) and use the same format over and over again. It will get much more natural - just give it time!

prmenrs, RN · Aug 20, 2005

Gompers--it probably has to do w/how that individual learns best. Some folks are visual learners, they see it, they've got it; some are auditory--they need to hear it; some are kinesthetic--they learn best when there's a motor activity (writing) involved. It sounds like your colleagues use a combination, auditory and kinesthetic, to get their day organized. I would have to take notes, too. Maybe not copy everything, tho.

Or they could be just nervous, anal compulsive, habituated and unable to cope w/change!!!! (ok, I'm kidding)

Gompers, BSN, RN · Aug 20, 2005

Or they could be just nervous, anal compulsive, habituated and unable to cope w/change!!!! (ok, I'm kidding)

This is actually right on the money. :chuckle

MsJessikia · Aug 21, 2005

Hi, I am a new grad in the NICU and initially found this to be difficult also, so I created my own, I'd be happy to email to you if you'd like. My report sheet if 1/2 sheet sized has fill in for most basic information such as age, weight, as well as O2 (included route, rate etc) and nutrition (w/ type, route areas to fill in such as OG ___fr. taped at _____cm @_____, residual______). I made a 12 hour grid to write in med/procedure times included a place for note and seperate section for data I want to make sure to include when giving report to the next shift. This has worked very well for me and even some of the more seasoned nurses have asked for copies.

I would love a copy of your "brains".... our unit has a little half sheet that everyone uses.. but its still not good enough for me... I need more organization!! TIA!!!

Jessica

SteveNNP, MSN, NP · Aug 25, 2005

We use 6x8" cards on our unit. I will usually divide it in 1/2 front/back. For each pt I like to keep my report organized by system

1) feed times/formula/OG/NG/repogle/residual, etc.

2)Vent settings, ETT depth/size, A's & B's, O2, lung sounds

3) cardiac stuff, PIV's INT's UVC/UAC's, depth, condition.

4) meds, PRN sedation!!!!!, times, calculations for how much to waste, etc.

5) labs drawn & to be drawn in the am, CXR, etc.

5) odds & ends, eg bracelet #, H&P facts, Socio Stuff.

Hope this helps!

SS

joboatgirl · Aug 27, 2005

We use 6x8" cards on our unit. I will usually divide it in 1/2 front/back. For each pt I like to keep my report organized by system
1) feed times/formula/OG/NG/repogle/residual, etc.
2)Vent settings, ETT depth/size, A's & B's, O2, lung sounds
3) cardiac stuff, PIV's INT's UVC/UAC's, depth, condition.
4) meds, PRN sedation!!!!!, times, calculations for how much to waste, etc.
5) labs drawn & to be drawn in the am, CXR, etc.
5) odds & ends, eg bracelet #, H&P facts, Socio Stuff.
Hope this helps!
SS

thanks,

and that might really help me, but for this particular instance, i need some sort of typed report sheet to take report quickly from the nurse and give report quickly to the oncoming nurse - to turn in for a grade to my instructor.

you're input helped though, now i have some ideas... thanks, amy