Suninmyheart 186 Posts Specializes in Cardiac/Telemetry, Hospice, Home Health. Has 6 years experience. Jun 8, 2008 I use SBAR (status, background, assessment, response) as a foundation for my report sheet. It is handwritten so I cannot post it but I love it.Basically in rows going down I have a line for each system (N,C,R,GI,GU,I,MS,PS,M). "M" is for metabolic which I also use for for comfort issues.Then in columns going across I have DX, HX, Status, TX, My ROS, Notes re D/C planning, status changes, etc.I can then easily talk about their diagnosis down the line, I see the hx and how it may affect the big picture, status is the nurses notes to me, tx is what are we doing, my review of systems as I do my own assessments, then notes on changes that need to be made etc. I like seeing the progression as it relates to each system as I run my eye across the paper. It help me think critically.Plus I always feel prepared to call a doc if I need to.I have some smaller boxes to the side that are VS, Meds, Labs.I also do a quick list of ALL the TYPES of meds (just classifications, like beta blkrs, ca ch blkr, lax, etc) the pt is getting and not just the ones I am administering on my shift. I need to see at a glance what is affecting this pt.I use one whole page for each pt. Most all nurses here do because our pts are complicated and we have a ratio of 3-4. I designed the page though so I can fold it in quarters and the med timeline and space for "to do" is on one quadrant and I can review it quickly as I go through the night.