RN Shift Report Sheets - New Grad

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Hello there! I just graduated nursing school this past month. I got a job in the SICU at a hospital in Pittsburgh.

In school I always made my own report sheets to organize my assessment findings, med times, iv, labs, etc. I have some ideas on what I would like to put on a sheet for my new job but not quite sure.

If any of you experienced RNs have any suggestions as to what to add or have your own copies that you are willing to share with me I would greatly appreciate it!

I can't wait to become an ICU nurse in 2 weeks!! ?

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Specializes in ICU and EMS.

Attached is the report sheet that I created. It is for a Medical ICU, so it doesn't include drains, etc. Feel free to use it and make it your own!

Report Sheet (1).doc

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Look under sticky threads of interest at the top of the main msicu sicu page there is a whole thread about this.

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Specializes in ICU, PACU,TRAUMA, SICU.

Congratulations on your new position! Welcome to the world of SICU nursing!

Actually, shift reports are the end product of what you did and accomplished for the past 8-16 hrs. with a brief history of how and why your patient got to the ICU.

I found it helpful to write down the following at the beginning of my shift, and added on info throughout my day. This ended up as my shift report:

-Med hx. of patient. Physical findings. i.e, Head to toe assessment ..heart, lungs, etc.

-Labs (past, present, and future labs to be done) their values, and what you did to correct them.

-IV drips, and if you titrated up or down and why? (Its always nice to have another drip mixed up and ready to go for the oncoming shift if you are running low.)

-Vent mode and settings, and any changes throughout your shift.

-Blood gasses (ABGs) and what you did to correct them.

-Lines- art lines, PA caths, cordis, bladder pressures, TLCs, peripheral IVs sites, etc. - where they are located, the condition of them, and when the dressings were last changed.

-Tubes and drainage from JP bulbs, hemovacs, foley caths, penrose drains, colostomies, iliostomies, wound vacs, chest tubes, rectal bags/tubes, etc. And their drainage amount and complications, clots?.

-I&Os .. any abnormal values? Are we on the right track with fluid balances?

-Sedation- what titration worked? Was a daily awakening done? How did that go?

-What are the CVPs, PA pressures, BPs , ICPs ..What are the goals?

-Skin condition- especially in trauma patients..rashes, incisional sites, trach sites, road rashes, stab sites, gunshot wounds etc. and the dressing changes you have done and what time you did them.

-Family- Who is the primary decision maker, any issues?

-CRRT? What are the replacement fluids, settings, dialysate, any issues with the machine clotting off?

-Surgeries- When they last had surgery, when are they due to do again. SICU pts may have surgeries every day or every other day.

-Road trips- CT scans, MRIs, Nuclear med scans, xrays, angiograms, ultrasounds, etc. Let the oncoming nurse know what the results were, when they were done, and when they are due to do again.

-Supplies- If your patient has an open abdomen, or any complicated wound with a washout due every day or every other day, your room will need plenty of supplies. I always let the oncoming shift know what supplies I have on hand and what I ordered. Its difficult to go scrambling for stuff when you are in a hurry.

-Fluids, blood products given, how much and why?

-What is the plan? What was discussed at rounds?

This is a lot of info, but I hope it helps.

Good luck!

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Specializes in ICU, PACU,TRAUMA, SICU.

An addendum to my previous post would also include any pain medication (prn or boluses) that were given for dressing changes, turns, etc. and how effective were these meds?

It seems that there is so much information being given to the oncoming nurse, but these details are necessary for our patient's sake, so that they can continue to receive excellent care.

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I am a tele RN and use the attached report. I used the basic same report for when I did Ortho Neuro, except had a few different labs on there.

I, personally, carry a clip board and like to use an entire sheet of paper for each patient.

I put their "sticker" in the top left corner...which supplies me with date of admit, date of birth, name and hospital number so that I can verify each time I pass meds.

If you go down the line on the sheet it should cover everything which is needed when giving report.

feel free to copy it.

I also have posted one on my blog where I often write about nursing experiences and stuff in general ...here's where the report is. Click the picture then you should be able to print it.

2 smart girls 1 fab blog

Good luck!

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v8grrl said:

I am a tele RN and use the attached report. I used the basic same report for when I did Ortho Neuro, except had a few different labs on there.

I, personally, carry a clip board and like to use an entire sheet of paper for each patient.

I put their "sticker" in the top left corner...which supplies me with date of admit, date of birth, name and hospital number so that I can verify each time I pass meds.

If you go down the line on the sheet it should cover everything which is needed when giving report.

feel free to copy it.

I also have posted one on my blog where I often write about nursing experiences and stuff in general ...here's where the report is. Click the picture then you should be able to print it.

2 smart girls 1 fab blog

Good luck!

No luck printing it, but thanks for trying!

Laurie

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Possibly resurrecting a flatlined thread here, but I just started orientation to CICU and am looking for something that gets me organized at a glance for beginning of the shift prior to seeing the paper flow sheet we have (at least until we finally transition over to Epic). I would like something for 2-3 patients per page that possibly would include a fishbone lab value, space for all gtt's and a place for the MD questions/reminders for EOS report. This will work until either epic straightens out all my kinks (since epic will fix everything wrong with the hospital system as we constantly remind ourselves) or until I know enough to just automatically ask all the questions needed to be a better than successful CICU RN.

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I am going to give a shoot,,, I need help with organization ;o) Looked over serveral this is my favorite!!!!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

brain sheet.......here are a few.

MTPMedSurg (2).doc

horshiftsheet.doc

FinalGraduateShiftReport.doc

1 patient Float.doc

5 Pt. Shift.doc

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Thank you, thank you, thank you!! I found this and tweaked it a little to my unit. I have been using it this week and it really helps! It prompted me to ask some really good questions during report!

This is for EMSnut45

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