Need help creating a report sheet

joboatgirl · Aug 27, 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.

thanks so much,

that helped a great deal... you have no idea, or maybe you do... i think i have a little more of the hang of it... amy

justjenny · Dec 12, 2005

Thanks!