detroitdano 416 Posts Aug 4, 2009 Mine is basic. I did med-surg for 2 years without any report sheet and did fine, my memory is decent so I guess I might not require as much as some other folks.My current sheet is:RoomNameAge/CodeHistory of Presenting Illness/Medical Dx'sNeuroCardiacRespiratoryGI/GUSkinLines/DripsLabsPatient/Family IssuesI list the times for meds down the side of the page, never what they are, that would swamp the page. I don't need to know what they are, just that something is due. If I need to know when a med is specifically due, I should probably be looking at the chart and not my beat-up folded piece of paper. Plus med times get switched around so much that section would be a mess, not sure how you guys keep it organized when that happens.I hit the BASICS of what they are in for in the HPI/med dx section and cover the rest under its subsection. Say they're in for VDRF with a pneumo, I'll write that in the medical dx and under respiratory put what vent settings/where the chest tube is, etc.
