Shift Report Sheets

Hi,

I work in a hospital that utilizes the electronic patient record system. However we are required to use shift report sheets for our own use so we can jot down our information for the duration of our tour.

Top Page - lists ward/unit census with room number, patient name, ID number (ususally social) and aquity level number. 1,2,3 ect. for each patient.

following pages are in box spread sheet form with the following info

room number, so on one page there will 3 patients listed per sheet.

Box 1 -

patient last, first name:

ID number:

Unit:

Dietary order:

Allergies:

Box 2: Goes straight across because it is same patient

Diagnosis:

Adm date:

Age:

Doctor:

Phone of Doc: pager #

Box 3:

Last set of last vitals recorded date and time: this whole sheet is printed from electronic record.

Box 4: has one nursing diagnosis listed; like self care deficit or airway clearance ineffective under this line is a blank area to write your own notes.

*We than use this information at the end of our shift to do our documentation per the electronic nursing note or progress note.

Hope this helps.

Very simple. We have two halls, so one page per hall.

It has the room #, name and a space for notes. That's it. You fill in the rest.

Since this is ltc, I'm assuming, the names etc dont change much.

Our 24 hr report sheets are carbon copy papers. It has a column for each shift and one for the resident name. You write in the name and the info under what shift it it...if it happens on 11-7 there is spaces to note on the same resident across the shifts.

hello,

i work in a ltc facility and here is how we do it...

we have 1 sheet per hall with the residents rm #, name, doctor, full/DNR and a place for fs if the resident is diabetic...right next to that is a place for you to put down any extra information. we even have a box on the bottom of the page for you to write in your results for the residents with fs ac&hs...its wonderful!