As a registered nurse, sometimes your biggest obstacle is the clock. So many tasks are required when managing a patient’s care and maintaining their vital stability. It’s easy to lose focus and end up accruing the unthinkable–incremental overtime! Not being organized and concise during your shift can eat into your personal time, negatively affect your confidence, and even jeopardize your patient’s safety.
Whether you are a new grad nurse who has not yet perfected your routine or a travel nurse who needs to remain grounded when navigating from hospital to hospital, there is something that can help you stay focused and efficient. That something is a nursing report sheet, often referred to as a “nurse brain,” and with good reason! A nurse report sheet can make your shift less stressful and boost your confidence as a nurse professional. Keep reading to find out about nursing report sheets and how to use one to operate to the best of your ability as a healthcare professional.
As a new grad nurse, I hated feeling disorganized and like I was forgetting something at the end of my shift. In order to ensure I didn’t miss anything critical when managing my patients’ care, I decided to make a list of everything I needed to do for each patient before the end of the shift. I noticed that some of the seasoned nurses would come to work and fill out what I later learned was their nurse report sheet. Once I learned the true value of nursing report sheets, I went home and made one for myself. Eventually I shared the one I made with any new nurse colleagues that inquired about it, and today I design, create and sell them online! I never thought I could reach out and help so many people who are probably going through the same ordeal I went through as a new nurse. If you’re still here reading, I hope that you can gain some value out of the following advice I have in sharing how I would go about using a nurse report sheet if I wanted to make the best use of my time, feel more confident during my shift, and communicate more effectively with my colleagues during change of shift report. But first let’s start off with the basics of what is a nurse report sheet?
What is a Nurse Report Sheet?
A nurse report sheet is your cheat sheet for the day. It is essentially a piece of paper you carry in your pocket or on a clipboard that contains information about each patient on your assignment. Nurse report sheets help you remember what is important, what needs to be performed, and what needs to be followed up on before the end of the day (or night).
Nurse report sheets include only your patients’ most pertinent information to their plan of care. A typical nursing report sheet includes elements such as the patient’s name, age, and medical history, as well as current medications, vital signs, labs and diagnostic results, and nursing interventions. The nurse report sheet may also include notes and instructions from the doctor, and may be used to track progress and changes in the patient’s condition.
The purpose of a nursing report sheet is to provide a clear and concise overview of a patient’s status and care plan, and to enable effective communication and coordination with other healthcare professionals.
Benefits of Using a Nursing Report Sheet
There are many benefits to using a nursing report sheet while working as a registered nurse. One of the biggest benefits is improved communication and coordination with other healthcare professionals. By providing a clear and concise overview of a patient’s status and care plan, a nursing report sheet can help facilitate better communication and collaboration between nurses, doctors, and other members of the healthcare team. If the physician, physical therapist, or patient care coordinator approaches you to have a productive conversation about your patient, you will be more than ready to participate and provide input.
Another benefit of using a nursing report sheet is improved patient care and safety. By helping you keep track of medication times and nursing interventions, a nursing report sheet can help prevent errors and ensure that patients receive the care they need. Additionally, by providing a clear record of a patient’s progress and changes in their condition, a nursing report sheet can help identify potential problems and facilitate timely interventions.
The final benefit of using a nursing report sheet while working as a registered nurse is that it can help streamline your shift and improve your efficiency as a nurse professional so you can clock out on time. Feeling more organized and timely can reduce your stress and even give you a big confidence boost when you need it the most.
How to Use a Nursing Report Sheet Effectively:
Step 1: Show up early.
Arrive to work a few minutes early with your nurse report sheet. Try to show up to work 15-30 minutes before the start of your shift. You can use this time to get settled, get a feel for how busy the floor already is, and make extra copies of your nurse report sheet if necessary. Sip your coffee, put your things away, and take some deep breaths during this time. Make note of if the current shift seems frazzled and behind with multiple call lights unanswered and last minute calls to the doctor pending. This could give you insight to how crazy your shift might start out in comparison to if the outgoing nurses are sitting at their computers in the nursing station finishing up charting, appearing relaxed and eager to give you change of shift report.
Step 2: Check out the assignment.
Find out which patients you have for the shift and write them down. Typically your manager or the charge nurse will have the next shift’s assignment ready for the oncoming nurses within 30 minutes to an hour prior to change of shift.
Step 3: Do some research.
“Prep” on your patients. Remember in nursing school when you would prep on your patients before clinicals? The process of prepping on your patients before your shift is similar to what you experienced during training. Fill in your report sheet with your patients’ room numbers, names, ages, diagnosis, medical history, allergies, etc. If you have a nice, detailed report sheet, all you will need to do is fill in the predetermined spaces with the information directly from the chart. Nurse report sheet can take the guesswork out and make your shift easier and efficient.
Step 4: Have some questions ready.
Determine any questions you might have for the outgoing nurse during the change of shift report. Figure out what you can from reviewing your patients’ chart, and then be ready to fill in any knowledge gaps during actual change of shift report time.
Step 5: Take report from outgoing nurse.
Get report from the outgoing nurse and take notes; update your nurse report sheet as needed during the report. Some nurses find it best to take notes during report in a different colored ink from the color they used during prepping. Since most of your report sheet is already filled out during your prep, the process of getting report will effectively be you reviewing the report sheet you already filled in, along with some notes and updates.
Step 6: Get started and update along the way.
Get started with patient care and update your nurse report sheet as you complete tasks throughout your shift. Check in every hour to make sure you don’t miss an assessment, medication time, lab draw, or other pertinent task. By the last hour or so of your shift, make sure everything on your report sheet is essentially checked off and updated. You will feel confident knowing that you did everything you needed to do and are ready to safely and efficiently report off to the oncoming shift.
Step 7: Report off and shred your nurse report sheet.
Properly dispose of your nurse report sheet. After you have effectively given change of shift report to the oncoming nurse with confidence, you can clock out on time and then be sure to discard your nurse report sheet properly. Your hospital or facility will most likely have a shredder bin where confidential patient health information is safely destroyed. This is a critical step so that you do not violate your patient’s privacy or break the HIPAA law. It is extremely important that you do not take your report sheet home with you. It is a tool that is to be used for the duration of your shift only. I found it helpful to empty my pockets and clipboards before I leave the floor.
Choosing the Right Nursing Report Sheet
When choosing a nursing report sheet, there are several factors to consider. First, you want a thorough and concise report sheet that will take the guesswork out of prepping for the shift.
Second of all, choose one that is perfect for your nursing specialty. ICU nurses would need a nurse report sheet that is highly detailed and likely only requires 1-2 patient’s per page. As another example, if you work in med-surg, choose a nurse report sheet that is tailored for a med-surg nurse, like this one:
Another factor to consider is customization options. Some nursing report sheets have blank lines or spaces that allow you to add or remove patient information fields or nursing intervention categories. This can be useful if you have specific needs or preferences.
Finally, consider utilizing the electronic health record (EHR) systems already in place at your hospital or facility. If your healthcare facility uses an EHR system, you might be able to print off your patient list with the necessary information already listed. This can save time and reduce errors by allowing you to easily access and update patient information.
Final Thoughts on Nurse Report Sheets
In conclusion, using a nursing report sheet can be a valuable tool for registered nurses. By improving efficiency, organization, and communication, a nursing report sheet can help reduce stress and improve patient care. I hope that the steps I laid out allow you to effectively figure out a beginning of the shift ritual that helps you feel more in control of your time and confident in your role as a healthcare provider.
