New to ICU-report sheet?

[ColleenRN]

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

[detroitdano]

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:

Room

Name

Age/Code

History of Presenting Illness/Medical Dx's

Neuro

Cardiac

Respiratory

GI/GU

Skin

Lines/Drips

Labs

Patient/Family Issues

I 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.