I'm fighting the urge to go off on a tangent, due to my extreme dislike of nursing report sheets. However, I realize this is a personal feeling and not up to date with the best practice. I'll start off with the fact that I have never tackled this issue, but as an experienced ICU staff RN I will provide my best advice.
Your facility's system seems efficient, admission/history/MD's/head to toe, very well done. However, I disagree on the report covering the entire course of admission. Let me give you an example,
You stated in your original post that your facility cares for post-op open heart patients, as does my current facility. Let's take into account a patient who is post-op day 2-3. I get three reports:
First Report: Admitted for CABG x4 on 11/17, Dr. Jones, Hx of XXX, NKDA, A&O, SR/ST, 2LNC, Cardiac Diet, Accuchecks ACHS, Right Hand 18G with D51/2NS @ 30 mL/hr, Mediastinal CTx2, to 20 cm suction drainage on my shift 70 mL, Uses Urinal, Up ad lib, dressing on sternum, leg wounds open to air, clean, dry, and intact, Labs are stable, ready for transfer to step-down unit, just waiting on the CT surgeon to put in the orders. End of story.
-Time of report: 1 minute 15 seconds, happiness of oncoming nurse (10/10)(Great Report)
Second Report: Admitted for CABG x4 on 11/17 (Lima to LAD, Lima to Proximal RCA, Internal Mammary to Distal RCA, and saphneous vein to Circumflex), Dr. Jones (CT Surgeon), Dr. Cake (Anesthesiologist), Dr. Brown (ER physician), Dr. Hemme (Out of Hospital PCP), Hx of XXX, NKDA (However, reports itching at the site of his peripheral IV, I talked to his daughter about the itching, she feels like its an allergy to the metoprolol he's been taking for 27 years, I put the allergy in the chart), He was extubated on 11/18 @ 0600, Swan/Cordis was pulled at 0612, A-Line was pulled at 0617, pressure was held for 5 minutes on each site, no excess bleeding was present, He is A&O but sometimes he forgets exactly what day it is (it's Tuesday and he thinks its something like Tuesday/Wednesday, otherwise intact neuro-wise). He is on 2LNC but earlier today he felt like he was short of breath, I put him on 3LNC and he felt better, I left him on 3LNC for approximately 18 minutes and then took him back to 2LNC, he's doing alright now. He's on a Cardiac Diet but he keeps eating whole eggs, he latest research shows that only egg whites are ok for cardiac patient, but the cafeteria keeps bringing him the whole egg, I don't know what's wrong with them. His accuchecks are ACHS but the daughter is concerned that his CBG is running > 120, so I held the dinner meal, according to the latest research hyperglycemia a major drawback in the recovery of post open-heart patients so I've been trying to keep the glucose level between 116-118. He has a right hand 18G that is slightly sluggish, does not draw blood, but flushes ok, with D51/2NS @ 30 mL/hr, Mediastinal CTx2 with a JP that are working great at 20cm of suction, drainage on my shift 70 mL, Atrium was last changed on 11/17, Uses Urinal, urine is slightly clear, I'm not sure what the specific gravity is but I think it's low., Up ad lib, uses the walker, daughter wants him to ambulate q2hrs per the latest research, dressing on sternum, dressing has approximately 13 mL of serosanguinous drainage on the dressing, right leg wounds open to air, proximal wound on the right leg is approximately 3 cm, wound on the distal right leg is approximately 6 cm, both are clean, dry, and intact, Labs are stable, but WBC count is up to 12 and HGB is down to 9, no orders for transfusion yet, they say he is ready for transfer to step-down unit, but he's still pretty sick (Day-Shift Nurse's Opinion).
-Time of report: 14 minute 35 seconds, happiness of oncoming nurse (4/10)(Too-Detailed Report)
Third Report: Admitted for CABG a couple days ago, Dr. Jones I think, now sure if he has anybody else on the case, OMG, daughter is crazy, she wants us to ambulate him q2hrs, can you believe that, we don't even have any PCA's, I'm telling you this place is really going to shi*. He has an IV site with fluids going, and Ashley actually expected me to help her move her new admission into the bed, can you believe that woman, she must be crazy. I hate this place, I only have a few more years to go till retirement, I can't wait, my husband is going to take me to Cabo, this place is awful. Oh, so sorry, I'm gossiping, he uses the urinal, by the way his daughter is crazy, I think she has some serious mental issues, I'll won't be back in the morning, oh, by the way his blood pressure decreased a little today, they still had the anesthesia concentrations plugged in the IMED (4mcg/250mL Levophed) in for his drips but I just used our drips (16 mcg/250mL Levophed), it's at 7.5 mcg/min (30 mcg/min in reality), I haven't called the surgeon yet, but he's going through a rough time with his divorce, I'd try to handle it yourself. See you later.
-Time of report: 57 minute 22 seconds, happiness of oncoming nurse (0/10)(Ridiculous)
As you can see, the type of report you get depends upon the nurse that you're getting report from. Now, biases aside, here's what my facility does.
-We use report sheets, I hate them, they are not updated on a regular basis.
-Regardless of report sheets, the quality of your report depends completely upon the previous nurse.
-In regards to the MD's cleaning up orders, I think it depends upon the orders. For example, I will discontinue an order for CO/CI/SVR/SVI/Core Temp q1 hour if the Swan/Cordis/Arterial Line was already pulled, however, I am more nervous discontinuing an actual scheduled medication, I believe this needs to be further clarified.
-I have never implemented a new report system, but I wish you the best of luck.