Shift report samples?

When taking report from outgoing shift, write down all pertinent info in sentence form. This may seem retarded but has worked for me for 11 years. No special form to fill in the blanks. Just patient name, dx, MD, and basically what we are doing for him. Fold it up and put it in your pocket. Nothing to carry around.

I've worked on a med/surg floor and the stepdown unit, and this is what works for me. I use a clipboard for each patient, it has my patient profiles (kardex), MAR's, and even though everyone is trying to go paperless, I always print the labs....

When I have time, I write down on a plain piece of paper:

name dob

docs/consults

admitting dx:

Presenting complaints:

history: just a synopsis...

N= Neuro

C=Cardiac--heart sounds, rhythm, rate; any dependent edema.....

P=Pulmonary

GI

GU

skin

New Treatments:

New Meds:

Concerns:

Lab Orders Pending:

then I just jot next to each one, that way when I give report, even if it's

been a crap day, I can have my thoughts in order because face it; some days everyone starts looking the same.....

I know we are all going paperless, but it works for me.

I've never had anyone complain about my reports....and if someone just wants to know the updates, i'll just read them that, and let them have my sheet if they want it.....

we get report on 13 pts, I use a plain A4 sheet folded in half lenghways, the fit 6 pts on one side and 7 on the other, just name, age, doc, diagnosis, relevant hx, jobs I have to do and any outstanding tests with a little checkbox next to each that can be ticked when same is carried out, its amazing how much you can fit on one little sheet to carry around in your pocket.

We are currently working on an SBAR format and possibly a kardex form and then bedside reporting. I came up with this sheet and where it says sticker - I put a pt. sticker there from the chart as that has the admission date on it, admitting doctor and MR# which is used when verifying a pt. for blood transfusions. I have been using it for a month now and I seem to cover everything, with little check boxes upon completion of tests and such. I get 4 pt.s on a sheet and just write small. Can't find where to attach but it is made in excel and the boxes are various sizes . I can fit 4 of these on a page, portrait size. These are my prompts and I've found them very helpful (I've bolded each box header, it's 2 rows and each header is it's own box. sorry I did not see how to attach it)..Thanks everyone for the other sheets. You will find you don't need a lot of room for AM Labs and DC plan and I just circle if they have fall precautions and note Isolation so that box is small. Hope this helps

STICKER/Allergies Diagnosis and Consults labs/e- replacement / Platelets/ WBCs/ H&H AM labs/DC plan Fall/Iso

History/Adv Directives Assess: LOC, Pacemaker/Monitor, O2, NG, Bowel, Bladder, Skeletal (Activity), Skin (incisions, WOC), Diet Treatmt (travel by) / Tests / OR results To Call /Recommendations Meds / Vitals /PCA IV's/I & Os

Fall/Iso

IV's/I & Os

Fall/Iso

IV's/I & Os

Fall/Iso

IV's/I & Os

Fall/Iso

IV's/I & Os