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 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.
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/
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
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Here is a thread where I posted my report sheet
SkateBetty
191 Posts
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