I used a set of sheets that I folded so that there was an edge that stuck out on each one, sort of staggered like stairs. Down that edge I wrote the hours and highlighted the hour for when the patient had meds due. When I stapled my sheets together I could see those med times for each patient at all times so I never missed a med. I had a basic run down of each of the systems starting with the head (Neuro) and finished at the feet. I only put on my sheet what was important. As the other poster said, it will depend on what unit you are working. So for instance on med Surg I always included how they ambulated, alert and oriented?, pmh, why they were here, and what was the plan for them moving forward. I only wrote down abnormal labs, and a basic review of any scans or tests. A note on family concerns or patient concerns and any significant event during my shift. Oh, and I always made sure the oncoming nurse was aware of any skin issues because those have to be watched. If I got asked something I didn’t know during report I just own it. My report sheet helped me focus during report. YouTube has a TON of great ideas from experienced RNs that helped me as a new nurse. It took me quite awhile to develop a sheet that helped me, so keep in mind what works for one nurse may not work for you.
That is something that has to be custom to your unit. During training on your unit you can begin to see what information is most frequently used and requested for your report. For instance, in the NICU, we wanna know gestational age at birth and adjusted gest age for that day, an abdominal circumference every 3 hrs for feedings, FOC daily, weight today and yesterday, vital signs every 1-3 hrs, labs, phototherapy, apneic episodes and desats. My brain would look much different than for an adult floor. A good brain is one that you can just check off any abnormalities.
My best nurse brain sheet has always been the care plan. Customized, relevant and an amazing tool that also serves in business, family life and personal goal setting.
