The hospital that I work at, per JACHO, has a sheet that is to be filled out, Kind of like a "portable" kardex that is supposed to pass from shift to shift with any changes but unfotunately, it is not used as intended.
What helps me out the most, is to take my initial report in black ink, and then throughout the day, I add to it in a different color of ink-usually orange of any changes, new procedures, labs, tests, changes, etc. We always get a sheet with the patient's name, age, dx, doc, diet, etc and then add the other stuff such as meds, IVPBs, IVs etc. In report, just try to give the facts. It takes time to get the hang of it, but as they say, "practice makes perfect"!