A nurse's life is hectic. It can be difficult to keep track of everything that goes on at work, especially when you are juggling a million things all at one time. That's why many nurses turn to nurse report sheets to help keep their work lives organized and efficient!
As a nurse straight out of nursing school, you probably are wondering what you can do to prepare yourself for that new job. No? Then you maybe have started work already and have had instances where you felt horrible after shift report.
It might be because the oncoming nurse had you feeling horrible for not having all your patient information ready during shift change, or they called you out because you forgot a few important details of the patient's care. I know how that feels, I have been there.
Don't worry! I have an excellent solution to this problem. I am glad you are finding ways to improve, which is why you are on my blog now. I will ensure you have all you need to give an accurate and in-depth report by the end of this read.
The answer to your problem is a customized nurse report sheet, a nursing report sheet, a nurse brain sheet, a brain sheet, or however you like to call it.
I promised a free customizable report sheet. I will attach it below. I will include a PDF version for those who love the way it looks and can work with it and a customizable version that will allow you to make changes to it as you prefer.
The link to the customizable version will take you straight to Canva, a straightforward, user-friendly graphic design website where you can easily tweak this excellent report sheet to your preferred workflow.
Below is a YouTube video I found to be very helpful in giving you a step-to-step guide on how to customize your report sheet, just in case you are not familiar with Canva.
This is my holy grail nursing report sheet that I have used for some years now after I had gone through numerous nursing report sheet templates. I found during this experimenting stage that all the nurse brain sheets I used had many things I liked, but I wished I could change one or two things here and there to suit my workflow but could not.
This is why I am sharing and giving you the option to customize yours just like you like it.
If you are interested in learning more about nursing report sheet, and how you can leverage it to improve your productivity and work flow, keep reading!
Do you know what a nursing report sheet is? Have you ever wondered why nurses have different styles of report sheets? We will discuss the definition and purpose of a nursing brain sheet, how to make nursing report sheets that work for you, and finally, why every nurse needs their custom version of a brain sheet.
What is the purpose of a nursing report?
A nursing report is a system by which nurses communicate important patient information. This communication allows nurses to know their patient's conditions, medications, and treatments. The nursing report also alerts nurses to any potential problems that may need to be addressed.
Why is this important?
The exchange of information between nurses is critical for the safety and well-being of patients. Nursing report helps ensure that all nurses are aware of changes in a patient's condition and provide timely interventions if needed.
Why do nurses use report sheets?
A nursing report sheet is a form that nurses use to document the care they provide to their patients outside of the EMR. Report sheets or brain sheets help nurses keep track of patient information, such as medications, treatments, and vital signs. They also help nurses communicate with other healthcare team members about their patients' status.
If you are like me, you probably have too much going on during your shift and many patients to take care of to remember every single thing during shift change.
Admitting and discharging patients in a single shift with multiple orders coming through within the hour, I know I cannot rely solely on my brain to remember everything, and I know I am definitely not alone on this table. This is why nurses need their nurse brain sheets for shift reports.
What should be included in a nursing report sheet?
The answer to this question depends on you as a nurse and the specialty you are working in. As a nursing student, a new nurse, or an experienced registered nurse, your sheet template should be designed according to your individualized workflow and specialty area.
Medical-surgical nurses' report sheets will have similar things to an ICU nurse's report sheet, but there will be some differences due to the difference in their specialty.
With that said, irrespective of your specialty and your personal preference, there are some key things that you should include on your report sheet to ensure patient safety and efficiency at work.
A nursing report sheet should include the following information:
Patient Information
Patient's name, room number, age, sex, allergies, code status, date of admission, attending physician, and any other pertinent identifying data (i.e., identification numbers or barcodes).
Placing this critical patient information should be done strategically on the top page, where you can refer to it easily in case of any emergencies. For example, you definitely will want to know a patient's code status when there is a code.
You don't want to be the nurse scrambling through sheets to locate this information, and nor do you want to be the nurse who needs to refer to the EMR to find this information when a patient is in cardiac arrest.
Diagnosis/problems
Primary or admitting diagnosis, medical and surgical history, hospital course should be the next things to include. This should include critical diagnostic tests done in the emergency room and any other abnormal blood tests and findings before inpatient admission. It also should include all the essential noteworthy diagnostics and findings during the inpatient stage.
Vital signs
Always leave a section to include patients vital signs-blood pressure, pulse rate, respiratory rate & temperature. It will be best to have all vitals signs written down through your shift so you can take a quick look at them and see any changes and trends that you might need to keep an eye on. Although these vitals signs will always be on the EMR for referencing, having it right in front of you makes it easy to visualize a patient's condition trends.
Laboratory results
Critical lab results or diagnostic findings are definitely worth a spot on your nurse brain sheet. Not only will that make your life easy during shift change and help with patient care and safety, but it will help you visualize a whole picture of a patients health from which you can always base upon to make critical decisions when need be.
Please do not write down all lab results and diagnostics. Only write the relevant ones so you do not overcrowd your report sheet. You could include results like white blood cell counts, hemoglobin, hematocrit, BUN, creatinine, potassium, and many more that are relevant to the patients' care on that admission period.
Patient assessment findings
This is where you write down all the assessment findings during your time with the patient. Structure your report sheet to writ down assessment from heat to toe so you can have everything organized. For example, you can start with any findings from orientation to the head itself and then to the respiratory system, the cardiac system, then the GI system all the way down till you assess the entire body.
Current medications
You can also include medications that are noteworthy on your nurse brain sheet. I would not recommend writing all the medications a patient takes unless its a handful which is not always so. I typically just write down important meds that are time sensitive- antibiotics, pain meds etc
Any pertinent notes
Always have a spot on your report sheet to write down things you need to communicate with the healthcare team. This spot is also good for noting down things you want to remind your self to do or tasks you will want to complete by the end of your shift.
The notes section will also be a good place to add all new orders and medication changes as well as discharge plan or plan of care so you can easily remember to pass it on to the oncoming nurse to ensure efficient continuity in care.
These are some of the basic things that every report sheet should have regardless of what specialty area you work in. Having all these info at one place will make it very easy to keep organized on your busy shift. When you have everything organized and planned out, it makes you very efficient. Plus, having a snap shot of your patients right in front of you will help you make good decisions when it comes to prioritizing care.
You will also have all of the pertinent information you will need for nurse handoff decreasing that shift hand off anxiety.
Why do you need a nursing brain sheet that works for YOU
When you're a nurse, there are so many things to keep track of- from patient information and medication administration to treatments and notes. And that's not even counting the other tasks you have to juggle on top of your nursing duties. Finding a report sheet that is especially tailored to your workflow makes it easy to keep sane and easily find all the vital information you will be needing to properly care for your patients.
How can I make my own nursing report sheet?
There are many different ways to make your nursing report sheet. You can find templates online or create your custom design.
Here are some tips on how to make a report sheet that works for you:
● Ensure the layout is easy to read and includes all the information you need.
● Include headings for each section, so it's easy to find information quickly.
● Use clear and concise language, so everyone who reads the report can understand it easily although no body might but just in case.
● Use diagrams such as the fishbone for visualize info like your lab reports, if needed.
● Print out a copy of the report sheet for every shift so you have it handy when you need it.
● Creating your nursing report sheet can be a great way to improve communication and patient care. By taking the time to create a sheet that works for you, you'll be able to work more efficiently and effectively during your shifts.
FAQs
Is it important to write a nurse report?
Nurse reports are an essential communication tool between nurses, doctors, and other healthcare professionals. They can also help document the care that has been provided to a patient. Plus, they're just good for creating a record of what happened during your shift. It is therefore important as it will not only make you efficient as a nurse and improve communication, but more importantly, it can help improve patient care and safety. Grab a FREE copy on this article.
How do I write a good bedside report?
Use a template as attached above where there will be all the critical information you will need to know on your patient, or you can follow the guide above to make one afresh on Microsoft Word or on Canva if you know how to use it. Alternatively, you can just write everything on a blank paper.
Can I use any report sheet I want?
Yes, you absolutely can as long as it makes sense to you. Feel free to use any template or format that works best for you. Just be sure to include all the pertinent information you need to provide excellent care to your patient in an easy-to-read format.
What should I include on my report sheet?
The layout of your report sheet will vary depending on what information you need to track. Still, standard sections usually include patient name and ID number, important patient specific info, shift info, doctor's orders, medications and treatments given, vital signs, observations, and diagnosis and many more. You can use the reference above or use the FREE nurse report sheet attached in the beginning of this post.
How do I organize my nursing reports?
Nurses need an efficient way to record not only what happened during each shift/patient encounter but also any additional details they may have learned throughout the day. The easiest answer to this question is, organize it based on what makes sense to you or what you can easily make sense of. Just make sure to include all the above pertinent info.
Conclusion
I hope this article has helped you understand the importance of nurse report sheets. From making sure everyone knows what is going on to using it to track everything that occurred during your shift, these forms are essential for any nursing team.
Download this customizable nurse report sheet today and personalize its content according to YOUR needs instead of spending hours fumbling around trying to find just the right brain sheet online. Until we meet again on my nurse blog post, happy nursing!
