Report sheets

I will share with you how I designed mine.

First, I print them on costco Neon Printing paper. No way I can put them down and they get lost.

I set it up like a head to toe P. E. Review of systems

ok at the top the usual, Name , Dx , age and Primary . You can get the consultlants from the chart.

Vital signs first. then Rhythm is tele, or unit

Next HEENT-------just write HEENT, you will know it.

Head

Eyes

Ears Nose and

Throat

then ABC

Airway & Breathing--place for O2 and o2sats, pluse lung sounds

then Circulation...all Heart and pulse stuff. and Labs IV's are under circulation

Next GI, GU

Potential Problems ***Most important, Hx of Ca or chemo , what day the 7th 10th or 14th day after chemo? (worst times)

Under potential problems I list the 3W's Infection and check Wind, Water and Wound

and risk of anything....fall precautions?

You have an outline of my sheet, I made, right off the top of my head, hope it helps organize, and don't forget S O PA P & E

I sent the one I used when I worked on a cardiothoracic post-op floor to your private email.

Let me know if you don't get it.

Jill (Pa)

I mentally divide my worksheet into three's - Past, Present, and Future. On the left is basic pt. info:- Name, age, Adm. Dx, Doctor, Pertinent History, and other things that have already happened like Lab results, tests that have been done and their results if revelent, other info I get from report like if the pt was in pain during the preceding shift, or what happened that day. The middle portion is for the assessment: Cardiac monitor rhythm, LOC, Lung sounds, Hep lock or IVs running, pulses, edema, foley, ambulatory status, incisions, dressings, and whatever else is pertinent. The right side is for things yet to be done: IVs to be hung , pending tests or procedures, fingersticks, notes to myself to call the Doc, give pain meds, NPO after midnight or special diet, etc. I write whatever I hear in report in a different color of pen, and whatever I, myself, add in black.