Specialties MICU
Published Jan 11, 2004
I'm moving over to ICU after being in medicine for 4 years. The nurses take report on regular loose leaf paper. I was wondering if anyone knew of a report sheet format I could use to be more oganized. Thanks Colleen
AZRN4life
15 Posts
I have never had a formal report worksheet... the back of a progress note page works fine for me. I am in love with my colored pens, though. I can't start report without a highlighter, a red pen and a black pen. I recently bought a green pen but have yet to figure out how to work it into report. When I do though... watch out!I also love printouts from a computer with patient info and current orders. That is where my colored pens really shine! I highlight meds, circle allergies in red and some things like stat labs get both the highlighter and the red pen! Maybe I'll use the red for report and the green for the stuff that happens on my shift. Hmmmmmm...........
I also love printouts from a computer with patient info and current orders. That is where my colored pens really shine! I highlight meds, circle allergies in red and some things like stat labs get both the highlighter and the red pen! Maybe I'll use the red for report and the green for the stuff that happens on my shift. Hmmmmmm...........
I do the same thing! I buy four color pens and have my system down: black for routine things, green for report, blue for new orders, and red for urgent matters and must-remember items (ex. allergies, procedures, etc). It keeps me organized at a quick glance.
Turley007
13 Posts
SBAR. Look it up-. It's new national patient safety issue. From the National Institutes of Health. SHow this to your leadership. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm
UpstairsCare
4 Posts
Unfortunately I can't just attach my report sheet to this post. I do have one that works very well for me in the icu. I've been using it for about 1 year now. Basically it covers the following:
pt id info/admit date
mds and consults
dx
recent history
remote history
drips
a list of almost all commonly done labs with lines to fill in for several days
system by system sections with a few prompts thrown in to make sure I hit everything in each system including incisions/ulcers/activity and whether they were bathed or not.
area for vent settings and ABGs for a few days
ett placement/size
area for swan readings: co, ci,...
area for radiology, cultures and other test results
and a handy check list section covering things like:
iv bags/tubing changed
labs drawn and sent
daily wt
wean eval
etc
I use my sheet over several days and keep adding to it. I try to write in pencil so I can update and change each day I have that pt. I'd be happy to e-mail a copy to anyone interested. It's in a wps format.
:typing
Would you mind sending me a copy via private message?
Thanks!
sirI, MSN, APRN, NP
17 Articles; 44,800 Posts
Please do not post your email address. Members can contact you via private message.
Thank you.
Conrad283, BSN, RN
338 Posts
Here's one that I recently devised. It's for night shift but you can just change the times for day shift.
That report sheet looks great, but I have a question as to what the numbers 01-07 and 20-24 are for?
Thanks
mark2climb
94 Posts
Those are the times in 24 hour format for a 12 hour night shift.
Thanks ...
TX_ICU_RN
121 Posts
SBAR is for communicating with the MD, PA, or NP you are calling to discuss a change in your patient's status. My hospital uses it and it is a wonderful tool for this, but I would not use it for giving nurse to nurse report.
patella
1 Post
I just printed out a slew of end of report sheets. I had made one myself, but wanted one that was more to the point. I just saved myself alot of time by downloading these. Thank you for all of your work that made mine easier. patella:)
Josiemom
great job
jangraciemom
6 Posts
Exactly SBAR is only for change in status not shift or transfer report