Nicely Organized Report Sheet

I fold it lengthwise and put a patient on each half of paper. I'll put all the important events on the top (reason for being there, labs, unusual events of the past few days, etc.) and then I'll list systems.

My coworker made a sheet that has caught on - basically the same thing, but she uses the entire sheet of paper, has a space for the initial report and then to write in changes over the shift - I just use post-its though.

You'll find what works best for you.

Good luck!

I too am looking for a good report sheet. The preprinted sheet we have for our pt's for the day has very little space to write as you go through the shift. I'd love to find a good one. So a big thank you to anyone that can help.

Rhonda

We dont use paper reporting anymore, so cant help out sorry

I don't know much about what form to use but for me a highlighter was absolutely neccesary. I would highlight meds, treatments, etc that absolutely HAD to be done!

I posted the one I use in the following thread:

https://allnurses.com/need-end-of-shift-report-sheet-t130750/

Here's one I created myself, in my spare time (way too much time on my hand). You can make it 2-sided. Let me know what you think.

Patient Shift Report Sheet.doc

Do you receive a rounds report in the am? If so you can utilize part of the rounds report and add on with the given report form the ougoing nurse...ie on our rounds we have the name, age, main dr, allergies, admit date on top. Then there are sections for diagnostic, diet, education, "nursing care" (vs q4hr) and md's on consult etc..when I receive report I then write on the top tele info, then what they came in for, what has happened since (tests, proedures) the iv line, wounds, blood sugars, foleys and then any open procedures...and of course any vital info..ie bp at 4am 88/56 etc..that way it is all on the one sheet...hope that helps.

Here's a link to a report sheet that I used this Summer in my externship. https://allnurses.com/need-brain-t173454/

Here's mine:

Report Sheet (1).doc

Very Nice!!!! Thank you for posting that, it is really helpful and well organized!

SkateBetty said:

So far I haven't found just the right thing for taking report. I need a full page form for each patient because I write kind of big, with a place for everything. Please, could you put yours out there, so I have a few to pick from? I need something more comprehensive, with everything right there; a place for each doctor's name, labs, treatments, GI/GU, CV, etc. Mostly I need this so I don't forget to ask for information I will need later, but will forget while taking report d/t my lack of experience.

BTW, which forum do the trauma nurses hang out on? I am a new step-down nurse, but don't see a trauma ICU forum.

Thank you!

Wendy

Here is a thread where I posted my report sheet

ReportSheet.doc

Here is a copy of my report sheet that I use...

CODE_____________________

Allergies___________________

DOCTOR

__________________________

DIAG

__________________________

__________________________

PMH

__________________________

__________________________

ISOLATION

__________________________

DRESSINGS/WOUNDS

__________________________

__________________________

__________________________

__________________________

WOUND VAC___________________

NEURO

__________________________

__________________________

RESPIRATORY

__________________________

TRACH SIZE____________________

VENT SETTINGS________________

VENT WEANING________________

IV_________________________

___________________________

___________________________

CARDIAC__________________

GI/GU______________________

LAST BM________________________

DIET/TUBE FEEDING

___________________________

___________________________