Share your ICU 'brain' report sheet

[General E. Speaking, RN, RN]

Trying to organize myself. Wondering if anyone wants to share their report sheet!!

Thanks

[RNTwin]

Just go down the systems: head to toe

• neuro
• cv
• resp
• gi
• gu
• skin
• lines
• drips

Very easy, I never write anything down.

[meandragonbrett]

RNTwin said:

very easy i never write anything down

The OP is new to critical care and probably needs something to help keep them a wee bit organized (even if just for giving report from it).

To the OP,

I say the best thing would be to create your own instead of using somebody else's. Some folks have to write every single little detail down and others don't write anything.

You'll see some folks with these elaborate report sheets and flowsheets to organize their day. That's entirely too much organization for me! I like it a little chaotic. You'll get the hang of it. I use nothing more than a blank piece of paper to write down things I'm told in report that I KNOW I will forget.

As far as organizing my day on when meds, labs, etc. are due....I look at the MAR and keep it stored in my head.

[BellaInBlueScrubsRN]

Search for "Report Sheet" at the top of the website. There are other posts with downloadable sheets.

A lot of us have gotten into the habit of writing down the pts history on a piece of paper and stuck it on the clip board. I love this! Don't always have time to do it though. When getting report I do mine the same always:

Original complaint at the top. Tests that have been done already. Abnormal assessments after that. History in the Left bottom, gtts in the right bottom. Abnormal labs middle bottom. ABGs, vent settings somewhere else.

Obviously you don't want to do it like mine, it just makes sense to me. Always do it the same way! And figure out what works best. If you need a paper to fill out, check out the other threads.

[CNL2B]

I've been doing this for awhile. I only need a little bit of stuff on my "brain" because we have a lot of stuff in our MR that I can refer to as well. The whole patient hx is entered into a database we can refer to at the touch of a button so I usually don't write down the hx. On my brain (I use a 1/2 sheet of paper)

Patient name, MR number

surgery, POD #, complications

allergies

drips and current rates

Then I write down times. My facility is a little weird in that all our stuff is done on the odd hour, so I write down, top to bottom 09,11,13,15,17,19. I write down under each time the timed stuff I have due, e.g. if I have meds due, I write "meds" under 09, 13, 17 or whatever it is. If I have an IV med due, I write "IV." Treatments, I write down "dressing change". "Labs". "Trach care." "Assessment." Whatever it is. This gets updated throughout the day. If I have stat or now stuff to do, I'll find room on the sheet and write it down with a little box next to it, and check off the box when it's done (I do this for a lot of paperwork type stuff as well, like "care plan", or whatever.)

The longer you do it, the less you'll need. I no longer need to write down my own assessment or VS on my paper or what I got on assessment/VS from the previous shift. I remember it in my head, and it gets charted in the medical record anyway. I know some people insist on writing down their whole assessment in sections: CV, resp, GI, etc... I don't need to do that anymore. I've can also remember stuff like the vent settings, the rate the TF is going at and what formula it is, etc. without needing to write it down, but if you can't yet, I would recommend throwing that on your brain for your own reference. I would NEVER go without a brain though -- I know some people do, but I would forget something for sure or something would be late. I need some method to check stuff off.

I don't know of anyone with any significant experience that uses a tool that they haven't made themselves. I think eventually you will figure out what you need from a "brain" format and make your own, whether it's hand-written out every shift (like mine) or if you put together a photocopied thing of your own design.

[General E. Speaking, RN, RN]

Thanks for the responses. It has been an adjustment going from writing things down for 5-6 pts on the the floor to 2 pts in the unit. I am actually trying to wean myself from jotting things down thru out the shift to actually taking my clipboard and charting at the bedside. :) I made up a report sheet for report which has helped

[PedsDrNurseTheo, ADN, BSN, MSN, DNP, RN, EMT-P, NP]

If you're interested still - I've attached mine. Days and nights. Word file - I can send .pdf as well if you want. Hope this helps.

I used to fill this thing out extensively - hour by hour. Now I use it to give report from and jot notes for things I want to ask the docs about. How things have changed . . .

CVICU Report Sheet2 PM.doc

CVICU Report Sheet2 AM.doc

[OnlybyHisgraceRN, ASN, RN]

My brain sheet is simple. I don't like too much stuff on it. I can't stand any pre made ones because I typically write alot more than what is provided. I keep my simple.