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We use an SBAR format (situation, background, assessment, recommendations), and I usually use a separate sheet for each of my patients if I am on a full 12-hour shift. Our sheet is divided into several columns (name, history, respiratory, IV, feedings, labs, meds, miscellaneous), and it is printed in a landscape view. We give report to fit that format...starting with name and history, moving on to care schedule and vital signs schedule, and then moving into respiratory status (this would also include any breathing treatments the baby gets), IV status (where the IV is placed, what fluids are infusing, any flush schedule, any drips), feeding and GI information (under this column we list feeding type and route, placement of feeding tubes, abdominal girth, and last stool), labs and studies for the next day, medications and schedule, and miscellaneous (any additional history that didn't fit in the history column, ECHO, head U/S, x-ray results, when the parents will be back, etc.).
We also have the same sheet divided in half and into thirds for nurses who don't take down quite as many notes, but I use the full sheet for each patient because I then take all my notes on the back of each patient sheets for my assessments throughout the shift.
Hope this helps!
I am trying to get a more concise flow sheet for our feed and growers rather than the trifold we currently use for everyone. I worked at a hospital that used them so i know they are out there i am just having a horrible time locating one. If anyone has a really good source or has one they can send me as a model i would be eternally grateful. We have a new director who actually wants our in-put and really hears what we are saying. She is all for it and i want to strike while the iron is hot. Oh, she makes us take lunch breaks too and even covers the babies while we eat if need be!! Imagine that! Anyway, any help would be appreciated, thank you and have a good day
Sure...I am supposed to work tonight, although it is overtime, so I might be cancelled (they are cracking down, which is sad for my wallet), but next time I am there, I will grab the sheets we have and scan them and send them to you. Is your e-mail in your profile? If not, you can e-mail me at thomas(dot)mm(at)gmail(dot)com and I will then reply to your e-mail.
LGarner279
9 Posts
I need some good examples of NICU report sheet. Just changed jobs, now working 3-11PM in a level2 unit. Many times have up to 3 babies . I would love to see someone else's report sheet so I could come up with a better for concise sheet. Thanks:redpinkhe