tuffRN

We use a DATAS report format: D - Patient's demographic (name, age, sex, where they come from - LTC or home), A - Assessment/allergies (I go through mine sort of head-to-toe: neurological, respiratory, cardiac, GI, mobility, GU, skin, IV access, diet, pain), T - Tests and test/lab results (if they have been an inpatient for a long time, I go with the most recent and/or pertinent tests), A - Alerts (Are they DNR? Confidential patient? Fall risk?), S - Status/discharge planning. Then at the end you can fill in the little details you might have missed during the rest, but I find that with this, most everything gets included.