If there is one thing I can’t stand, it’s a long, insignificant report. As one of my previous orientees expressed regarding another nurse, “Does she want milk and cookies with that bedtime story she is telling for report?” I have never forgotten this because it made me laugh so hard. In addition, when I am done at work, I want to leave as fast as possible and my counterparts want the get started as fast as possible. Every unit has their own intricacies and themes when it comes to report giving, so if you are a new nurse, or newly employed on the unit, it makes it easier to figure these out sooner than later.
However, most importantly, it is empowering to be able to give an accurate report and have the necessary information on your patients at all times to tell to various providers. For instance, imagine a patient is crashing and you need to intubate. The physician wants to use succinylcholine for rapid sequence intubation and asks, “What is the patient’s potassium level?” You will know because you have it on your report sheet.
I am certainly not perfect at giving report, but when I worked full-time I developed a nearly, fail-proof system. First, I created a report sheet, which I have edited with every job I have taken. I made sure to fill out all of the information on the report sheet, and if I got nervous during report or was too tired to remember something, I would always have it written down. If you haven’t figured this out yet as a new nurse – write it down, you’ll never remember.
I’m going to keep this short and sweet. I have attached my personal report sheet from my jobs in cardiac surgical intensive care units. There is a lot of extra on this report sheet, specifically for my previous CVSICU. I would encourage you to edit it to your area of practice, so it is more beneficial to you. I have also provided a picture of how I would fill it out. No, this is not a real patient, but much of it is very accurate and parallels patients I have cared for. Some of it is filled out for the sake of showing you how to fill it out. I do realize this info is specific to ICU nursing, but hopefully you find it useful.
Finally here are the steps I use to giving a succinct report.
- Overview (name, age, date of birth, allergies, code status, isolation, or other precautions like limb, seizure, bleeding etc.)
- Brief medical history
- Date of admit and reason for admission (chief complaint or type of surgery)
- Significant changes on your shift
- Systems (I follow the list on my report sheet)
- Skin issues (Include wound consults, specific instructions for dressing changes)
- Lines (When dressings need to be changed)
- Drips (tubing expiration)
Have a wonderful shift!
Download my report sheet here: Report Sheet_ICU1
Here is a PDF version: Report Sheet_ICU1
Here is a picture of it filled out: Report sheet example