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Discussion

Organized format/template for report

Hi all! Does anyone out there have an organized format to use for note-taking while receiving report? I know many nurses have different systems. I'm in the process of trying to get a handle on organization in relation to management of care. I am familiar with SBAR (which I find helpful when giving report). However, I am looking for something more specific including body systems, labs, orders, etc...to help transfer patient information into note form to refer to and add on to throughout the shift. If anyone has a template which they use and find helpful, please share. Thank you in advance!

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