The report sheet should contain the patients basic information such as name, attending physician, allergies, reason for admission, diet, vitals and consults. These are only a few of the items you can have on your report sheet. Every nurse is different and likes to have different information. Whatever the nurse thinks is vital and critical to know on their patients should be on their report sheet.
There are numerous benefits to using reports sheets because depending on your type of unit you can have up to seven patients. That is a lot of people and information to remember. It is so easy to get patients, medications and diagnosis confused with one another. These sheets give you quick access to vital information. Imagine being in the middle of something with no access to a computer and the doctor calls you asking for information on your patient. You can whip out this paper and hopefully help that doctor out. This also helps keep your charting more accurate. If you are not able to document while you are assessing then write it down on their report. This way when it is 4 hours later and you finally have time to chart you are questioning “Whose lungs sounded diminished?” “What that room 7 or 10?”
Some nurses do not use report sheets and that is fine and all but as a new nurse and if you are a nursing student then I highly recommend you use one. The amount of information on patients can be overwhelming and you must have your information accurate. Plus, why cause yourself unnecessary stress by being unorganized. I created my very own report sheet and customized it to my job. I work on a Medical-Surgical Post OP floor but I believe this is a great basic report sheet for any Medical-Surgical floor. I even added little check boxes to mark off as I complete my required work for the day.
Another pro tip is to use a multicolored pen! I write anything in red that is critical or what I must take care of. This way it stands out and I am less likely to forget. These include any nursing orders like wound care, heparin drips, insulin drips or if my patient is on telemetry. If you would like a copy of my report sheet I have included a downloadable link >>here<< Feel free to customize it and share with others.