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.

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.

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.