Nursing Report Sheets

by Andria RN · 1 comment

in ICU

Some of the best advice I got as a new grad ICU nurse was to make my own nursing report sheet. A report sheet is helpful, for example, when the night nurse is reporting off to the day nurse, and there are pending results or follow up needed (as is often the case with our sicky sick ICU patients!).  As a new grad, it is common to struggle with good organization, time management and “flow.”  If you do not have an organized report sheet, the continuity of care may be broken.

Some facilities use a voice recorded nursing report where you log in, type the patients medical record #, and then listen to the last’s nurses’ recording of patient events and history. Some do group report where all nurses listen to an updated report of all the patients (usually in smaller units) and then there is always the good old face-to-face report.

I would suggest waiting a few weeks to see how your new unit “flows” in regards to giving report, but once you feel comfortable, hop on the computer (or hand write and photocopy!) and build your own report sheet that flows in exactly the order you want to report off in.  If you use a telephone system, write down the information in the order of the telephone prompts.  You can always add or take away information in the future.  And, as you gain experience, you will find that you rely less heavily on your report sheet and more on your memory.

For example:

  • Patient Name, DOB, Attending, Allergies
  • ICU Diagnosis
  • Past Medical History
  • Past Surgical History
  • System by System Review: Cardiac, Respiratory, GI/GU, Hepatic/Renal, Endocrine, Skin
  • IV access (Central Line, PIV, Pulmonary Artery Catheter, etc.)
  • Pertinent Lab Work (increased WBC, decreased H&H, etc.)

Tips- inside each system list items that you can circle or check that will make report quick and organized.  For example, in Respiratory, write out possible vent settings (Pressure Support, Assist Control, etc.) and for GI, list out dobhoff tube, OGT/NGT, PEG tube, etc.  If the patient has any of these, you can circle and write notes next to it if you need to.  It is also VERY helpful to have hour time slots listed where you can note when medications are due, labs are due to be drawn, assessments need to be complete, and charting needs to be complete.  Having this visual cue will benefit the new grad who often becomes overwhelmed with the task-oriented nature of ICU nursing.

Do you have any advice for new ICU nurses learning to give report or hand-off?  Do you have any report sheets you’d like to share?  We’d love to hear from you!

  • WorldNursingJobs

    Great tips you got here! Just want to add to these, when making a nursing report sheets on your own, be brief about it and don’t forget to share your new way of doing this! Kudos to all nurses!

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