Ultimate Nursing Report Sheet Database & Free Downloads
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33 Nursing Report and Brain Sheet Templates
I get it . . .
I was there once too.
Notes on my hands, on alcohol swabs, on scraps of paper, and a few scribbled on the gloves I was wearing.
Staying organized as a nurse is no joke.
"After about 6 months working on the floor as a nurse, I finally had MY method. I'd found a nursing report sheet (brain sheet) that worked for ME."
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It was like the entire world had changed!!
I didn’t feel like . . . this . . .
I was actually getting some work done!
You Need a Nursing Brain Sheet That Works for YOU
For the longest time, I have tried pushing the brain sheet that worked for me onto new students and newbie nurses. I’ve changed my tone.
About a month ago we sent out a signal on social media. Asking for nurses and nursing students to send us the report sheet or brain sheet that they were currently using so that we could compile a database of the BEST nurse brain sheets.
The Nursing Brain Sheet Database
The response was AMAZING (to say the least). We received over 100 report sheet templates from nurses working in MedSurg, ICU, ED, OB, Peds, Tele . . . you name it.
We’ve spent the last two months combing through all the submissions and have narrowed it down to the top 33. It turned out pretty awesome and provides the BEST resource and collection available of templates for report sheets and brainsheets for nearly any specialty. . . . did I mention it’s FREE?
I will give you a preview of each one.
Here it is!
Wondering What’s Inside?
Want a sneak peek at some of the best brainsheets we received? No problem. Let’s take a sneak peek at all of them and talk about why we chose to include it in our list of the best nursing report sheet templates.
The images below are just small glimpses of the actual pages. To get the full FREE database . . . just click here.
I’m going to show you examples of 20 of the 33 nursing brain sheets that are included in the database.
1. Handoff and Nursing Report Sheet
This is the report sheet that my preceptor used to make me fill out prior to the end of each shift as a newbie. To be honest, at first, I was so annoyed that I had to spend like an hour at the end of each shift filling this out. It wasn’t until I realized I was able to give a badass report that I was finally grateful she made me fill this out.
What I like most about this sheet is that it breaks down each body system and makes you really think about what is going on with your patient . . .from head to toe.
2. Ultimate Clinical Brainsheet
This is a custom one that I made for myself while in nursing school.
I think it outlines nearly everything a nursing student should be thinking about during a clinical day . . . including an area to write notes about things you want to look up later and learn more about.
3. 4 Patient Simple Tele Sheet
Some people like it simple . . .this is the sheet for you. With slight prompting, this sheet makes a great tool for the MedSurg or Tele nurse on the GO!
Everything You Need To Know About Nursing Time Management
4. 4 Patient Simple Nurse Task Sheet
I love this one. At first glance it looks basic . . . but at closer inspection, you start to see all the details and information you have available with it. From lab values to foley care, to last pain med, this is would be a great one for a nurse that has a flow and just wants a simple push to stay a bit more organized.
5. Vertical Nurse Brain sheet with Assessment Diagram
I’m a visual learner. This one just grabs my attention. I like the top section for the “essentials” like blood sugars, DX, and Pt info. I also really like the area below the charts to draw little notes about your physical assessment. I really like this nursing brain sheet for beginner or experienced nurses.
It can be helpful to SEE what sort of findings you came up with during your initial assessment.
6. Just the Boxes
I’ll be honest . . . after a couple of years of being a nurse, my “brainsheet” has evolved into more of a few freehand drawings on a sheet of paper. If that sounds like you, this is probably the one for you. With little more than a few suggestions . . . this is a pretty basic organizer for nurses.
7. Postpartum Nursing Brain Sheet
My experience with postpartum nursing is limited to the birth of my two kids and a few shifts on the OB floor as a nursing student . . . and I’d like to keep it that way.
Despite my limited experience, this sheet looks pretty bitchin’ . . .you have to admit. With places for mommy and baby assessment, this one seems to have it all!
8. 8 Patient MedSurg Nurse Report/Brain Sheet
Until patient ratios finally become mandated . . . fingers crossed . . . we just need to face the truth that some of our MedSurg brother and sister will be taking 8 patients.
Even if that isn’t your reality, this is still (maybe) my favorite.
I like the layout. I like the space for 3 sets of vitals per patient. I like the space for notes, meds, assessment, and more. This one really packs a lot of information into such a small little space.
You might also want to take a listen to this podcast episode about staying organized in clinicals.
9. Mom-Baby Brainsheet
Like I said above, not being an OB nurse I’m not sure I can fully appreciate everything that is on this page . . . but it looks awesome. Here’s a small screenshot of this one.
10. Detailed ICU Nurse Report Sheet
Alrighty! Now we’re speaking my language. What you will notice about a lot of the ICU sheets included in the database is that they are full sheets dedicated to just one patient.
When you work ICU a lot of times you only have two patients . . .sometimes even just one.
But you are expected to know EVERYTHING about that patient so you need to have an organized way of keeping track of all of that information. This nursing report sheet does a pretty good job of outlining the information an ICU nurse needs to know.
Here’s a snapshot:
11. Charge Nurse Report Sheet
Yep. Even charge nurses have to take report.
In fact, when I was working as charge nurse of our 34-bed ICU I would arrive about an hour ahead of all the staff nurses to take a detailed bedside report of EVERY.SINGLE.PATIENT.
It was a lot to keep track of during a 12-hour shift.
A report sheet like this does a great job of giving the charge nurse a few boxes to check . . . of just the important stuff (vent, isolation, foley).
12. 5 Patient Vertical Brainsheet
Every now and then I will post a pic of a typical IV pole for an ICU patient. People will say “I could never do that” or “looks too busy” . . .here is my response. I would rather have 1 or 2 patients that I am in charge of and trying to keep track of than ever try to keep 5 or more patients straight.
Respect to the MedSurg nurses out there . . .
Just looking at this nursing report sheet makes me scared!
13. ICU Body System Report Brainsheet
Here is another great ICU sheet with an entire page dedicated to just one patient.
Are you starting to see the difference between the different floors?
Being a nurse means something slightly different on any given floor. We all have the same goal, the same passion for caring, and helping, but it takes a different breed to work on each and every floor.
14. Boxes, Boxes, Boxes Nursing Report Sheet
Do you love neat, clean, tidy spaces?
This might be the one for you.
One thing that this one adds that the other do not have is a place for a “password”. Often times in ICU settings families will request that no information be given to anyone that doesn’t have a “family password”.
I like that this is included on the sheet because many times you will forget as the shift goes on that you need to ask for the password when someone calls. Having it right in from of your face all shift seems like a good way to avoid that mistake.
15. Hourly Brain Sheet for Nurses
This one is cool because it focuses on dividing your shift up into hours.
I think this does a couple of things: it helps you to stay organized and it kinda helps the time go by faster.
Also, if you look closely it already has the hours written for day and night shifts. . . nice touch. You will give an amazing nursing report with this sheet.
16. Cardiac Brainsheet
Do you work on a specialty cardiac floor or post cath procedural floor?
This one is designed for the cardiac nurse with all kinds of cool reminders and spaces unique to the cardiac floor.
17. Emergency Department Patient Care Sheet
Emergency nursing is high volume/high turnover.
You might only have a patient for a few minutes. Or you might have the patient for the entire shift.
Many ED nurses find it hard to have any sort of report sheet because they are focused primarily on the life-saving procedures before sending the patient upstairs.
As you can see . . .this sheet focuses on the ESSENTIALS . . . nothing extra.
18. Nursing Rounds Report Sheet
If you work in a tertiary care facility one of the most important parts of your job is figuring out how to best help the patient progress from the hospital.
Many hospitals have interdisciplinary rounds on a daily basis where patient needs are discussed with the entire team (MDs, nurses, PT, OT, Speech . . . etc).
This is a wonderful sheet that will help you to think in a team model and how your care fits into the entire plan.
19. Neuro ICU Brain Sheet
You know I couldn’t make a nursing brainsheet database without including a special one from the Neuro ICU (my home).
If you are a neuro nurse or an aspiring neuro nurse . . . this is a great template to start with as it helps you to focus your assessment and care around the neurological system.
20. Whitespace Nursing Assessment Sheet
Having plenty of space for notes is one thing that many nurses want in a great report sheet. This one focuses on note-taking space and keeps all the assessment information on the outer edges.
If you are a note-taker. . . this is the one for you!
But Wait . . . There’s More
I’ve always wanted to say that.
But seriously . . . I’ve only shown you small portions of 20 of the 33 nursing brainsheets included in our massive database.
Download the entire FREE library of nurse report sheet templates and pick out the one that works best for you.
Try them all out . . . shoot switch it up and find what really works and helps YOU.
Feel free to download, print, make copies, and share the database.
Oh . . . and a HUGE thank you to all those that submitted their brainsheets to the database.
Download All 33 Brainsheet Templates
To download all of the templates in PDF format just click on the button below. Once you’ve downloaded them please consider sharing this page with a friend:
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What’s Included on a Nursing Report Sheet?
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Nurses are the cornerstones of the healthcare industry, providing an essential link between physician and patient. One element that helps nurses maintain continuity of care for their patients are nursing report sheets (also known as nursing brainsheets).
These sheets are typically produced for nursing colleagues at the change of shift.
In nursing school and clinicals, you need to know about creating and using nursing report sheets to provide the best possible care for patients (and to help your fellow nurses do the same after graduation).
What are Nursing Report Sheets?
Nursing report sheets (also known as patient report sheets or nursing brain sheets ) are templates nurses fill out with important patient information.
These sheets are handoffs at the end of each shift and are given to the new nurse taking over for the next shift. For example, if a nurse comes in for their night shift, they would get a nursing report sheet from the previous nurse finishing their shift.
Nursing report sheets might also go with patients if they are being transferred to another hospital unit, such as from the pediatric unit to the ICU.
So, what goes on a nursing report sheet? The following bits of information are typically included:
- Attending doctor
- Records of medications
- Medications to take during breakfast, lunch, and dinner
- Important vital signs (e.g., temperature, heart rate, blood sugar, and blood pressure)
- Basic patient information (e.g., name, date of birth, sex, and room)
- Work nurses and doctors must perform for the patient during various shifts
- Lab results and pending lab work
- Future procedures
- Additional notes about patient requests, and more
Why are Nursing Report Sheets (or Nursing Brain Sheets) Important?
A nursing report sheet provides essential directions on patient care to the incoming nurse – who might not be familiar with the patient and their medical needs – before change of shifts.
As a nurse, how does a nursing report sheet benefit you, your patients, and your colleagues?
- Fast access to vital patient information
- Better time management ability
- Helps keep track of multiple different patients
- Improves safety and care of patients
- Increases the ease and accuracy of charting
- Helps manage shift duties
- Saves time and increases patient comfort
- Serves as a legal document related to patient care
Nurses often refer to these sheets as their “brain” or nursing brain sheets — essential to keeping nursing life organized.
Nursing Brainsheets vs SBAR
Keep in mind that a nursing report sheet is different from an SBAR tool (situation, background assessment, recommendation tool). An SBAR tool includes important health history, an assessment of the patient’s current state, a briefing of recommended action, and so on.
While the SBAR tool and a nursing report sheet are not the same, nurses use the SBAR tool to help guide the creation of the nursing report sheets.
What’s Included on a Nursing Report Sheet?
Just as there are different types of nurses in different health care units, there are also various types of nursing report sheets – which often have different organization styles and required information.
Whether you plan to become a registered nurse, med surg nurse , or will need an ICU nurse report sheet, knowing how to create and utilize different styles of nursing brain sheets will be essential to success in your future career.
In detail, what can a new nurse expect to find on a nursing report sheet?
Basic Patient Info
Of course, you must know your patient’s name, age, and sex. Other basic patient information might include:
- Admission date
- Room number
- Name of doctor(s)
- Updated diagnosis
- Allergies or sensitivities
- Medical history (including pre-existing conditions or dangerous infections)
- The patient’s code status
- Advanced directives (such as DNR)
- Power of attorney data
- Living will information
Current Patient Health Info
The nursing report sheet must display the patient’s current vitals, most of which are recorded through regular nursing assessments . Vitals help identify important statistics for different bodily functions, including cardiovascular blood pressure, temperature, oxygen levels, what the patient ate, etc.
Patient health information that is valuable for the next nursing shift includes:
- Neuro information (such as the level of consciousness)
- Musculoskeletal data (such as the patient being ambulatory or bedbound)
- Patient dietary restrictions and other gastrointestinal or urinary considerations (such as whether they are incontinent or need a catheter)
- Any wounds or pressure injuries on the skin
- What medications the patient is taking
- What IV access the patient has, and if they are getting continuous fluids (and if so, the type of fluids)
Ongoing Patient Care
As a nurse, you’ll provide medication or monitoring on a regulated basis that you’ll then record in the nursing report sheet. For example, a nurse might have to test the patient’s blood sugar at certain times during the day. Your brain sheet will help you determine if the results fall within normal lab values.
Some things you might find regarding ongoing patient care include:
- What dosages of medications need to be administered, and when
- If the patient requires certain tests that day
- What to expect for normal test values for that patient
- If the patient is supposed to be discharged at a certain time
- If the patient is scheduled for future procedures that require preparation
- The expected duration that patient may stay at your medical facility
Clearly, the nursing report sheet is there to help keep things organized so you never miss a beat.
Patient Notes
The patient notes explain things not fully covered in the nursing report sheet template. For example, if the patient hasn’t moved their bowels for a few days, you may wish to write a note as a reminder to discuss the situation with the medical team to see if a laxative or enema should be prescribed.
Read more about patient notes in our post about taking nursing notes .
Other patient notes you will likely find on your nursing report sheet include:
- If the patient speaks a foreign language, and how to contact a translator.
- Emergency contact information.
- Any patient triggers or noteworthy care patterns.
- Patient preferences, such as food choice or room temperature.
- Patient routine reminders, such as needing to walk around 3x a day.
Special patient notes are generally discussed verbally with the incoming nurse to ensure proper patient care.
Take the Next Steps to Become a Nurse
Staying organized as a nurse is vital to keeping your patient happy and healthy. A nursing report sheet serves as the blueprint for everything someone would want to know about your patient – and you’ll find a lot of the elements above on many templates regardless of which nursing specialty you choose.
What’s on a nursing report sheet is just one of the many things you’ll want to know as you begin your journey as a nursing student. And you’ll need a supplemental tool for your lectures to ace your exams.
Access everything you need to know to pass your nursing school exams.
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Nursing Brain Sheets for Beginners
What are brain sheets.
Nursing Brain sheets are summaries that help nurses remember their patient’s particulars. Most veteran nurses already have brain sheets that they depend on, but new grads need to work to make their sheet as customized for them as possible.
Updated: Feb 20, 2020 Published Mar 16, 2015
- #Brain Sheets
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Nursing brain sheets go by many names. They are called report sheets, security blankets, flowcharts, to-do lists and everything in between. What are they exactly? Nursing brain sheets are those papers that have all of the information on your patient. You will have your history, diagnosis, meds, lab values, and so much more. In fact, brain sheets are like fingerprints. No two seem to be the same. Some hospitals are forcing nurses to use standardized brain sheets, but you can still make them work if you take some steps to customize them.
Your brain sheets will help you out throughout your shift. Just by looking at them, you can easily recall to mind who a patient is, what they need, and what you need to watch for. It is easy to forget when you have six patients. When you have two, such as in the ICU, there is so much to remember on each patient that you almost have to have a more detailed brain sheet. Essentially, these brain sheets are your ability to admit you are human. They help with report, it is true, but their number one usage is keeping you organized throughout your shift.
Your First Nursing Brain Sheet
When new nurses hit the floor, they usually don't have brain sheets. Most don't even know that such a thing exists. Although you may be able to get by with a notebook, that will quickly become confusing, messy, and completely unhelpful in an emergency. But what do you need to know? One of the best ways of breaking into brain sheets is using your preceptor's sheet. This way, you will be keeping the same information that they are, and you will be sure to follow along.
This brain sheet may not work for you, and that's okay. Maybe you like more emphasis on labs than on history. It is a very personal thing. As you get to know your coworkers, take a peek at their brain sheets. Some of them may have items that you want to include in your own. Most nurses are more than happy to give you a blank copy of their sheet. You really want to get a sheet from a nurse who seems really organized and knows what they are doing. Usually, preceptors are the model for this, but becoming a working nurse means finding what works for you.
Modifying Nursing Brain Sheets
Once you've collected a few nursing brain sheets, you may be tempted to make your own. This is a great impulse, and you should follow up on it. The first thing you will need is some sort of word processing or spreadsheet program. If you don't have Microsoft Office, you can download a free program called Open Office that will essentially do the same thing. Don't overlook Google Docs, either, as they have a great deal of the same capabilities. They may not be as robust, but they can help you make your sheet.
You have to make some decisions when coming up with your first brain sheet. The first choice is which program to use, and that's going to depend on how comfortable you are. Spreadsheets are awesome for tables, and that's what you are going to be making. However, spreadsheets can intimidate some people, and they would prefer to use a word processor. If you feel you are better at making tables and formatting data in the word processor, then go for it. The second thing you need to decide is what to put on your brain sheet. Look at your samples. Make a list of what you need. If you find you are always scrambling to remember when meds are due, then make a checklist of the times on your shift that you will pass meds.
Also, give some consideration to the space that you have for this information. It may be great to have a comprehensive sheet, but that's going to take up a good deal of room, necessitate writing down all the information, and then carrying those papers throughout the day. In short, the smaller you can get it, the better it is. Remember: you almost always have a computer that is on hand that can allow you to look up results and histories. Maybe keep a few important or out of range labs on your sheet, but there is no reason to write them all. You have to be picky about what goes on your brain sheet.
Coming to Terms with Your Nursing Brain Sheet
As with most of nursing, brain sheets are a journey. You may need to adjust the sheet many times before you get something that makes sense to you. That's why you probably don't want to stay with any nurse's personal sheet. It is designed to help them remember what they usually forget, and you need a sheet that is tailored to your specific brain blind spots. Keep the file that you use to make your sheet handy. You will be back to it to make changes in how the document looks.
In the end, your brain sheet is your best friend. There is nothing better than having a brain sheet in a code when a doctor walks in and wants to know all about the patient. If you are ever going to forget, it is at this moment. You can fall back on your sheets, provided they are comprehensive and filled out, to help you manage the emergency. They will also keep your patient safe. Every nurse has blind spots, and these papers are like side mirrors that keep you aware of your surroundings. Take your time to formulate the sheet so that you can keep yourself organized. Also, take care to shred your used brain sheets at the end of the day, because they can be a HIPAA violation if they manage to come home with you. One day, you may be surprised when a new grad or coworker asks for a copy of your sheet for their usage.
If you've had any helpful nursing tips passed down to you from preceptors, share them in the comments with new nurses who may need the help. You can even share your brain sheets if you have them handy.
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About Lynda Lampert, RN
Lynda is a freelance medical writer with experience in telemetry, med-surg, and ICU.
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canigraduate
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I miss Daytonite.
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canigraduate said: I miss Daytonite.
I know! Daytonite had such great posts. I don't remember if the user was male or female, but they definitely contributed to the forum in such a great way -- esp. with brain sheets.
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The documents below are a repository of “brain sheets” that may be helpful to you for organizing patient clinical data. Such documents are often especially helpful when you are giving and receiving report on patients to other nurses or healthcare professionals. You may freely download and use these brain sheets for your own purposes. Keep in mind that some institutions place limits on what information can be collected and shared about patients; always follow your institution’s applicable guidelines and regulations when recording patient information.
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Nurse's Brain, Part 4: Giving report to the oncoming nurse
by Cathy Parkes July 11, 2020 Updated: January 18, 2023 4 min read 6 Comments
RECAP: What is a Nurse’s Brain?
A Nurse’s Brain, also known as a nursing report sheet, is a term for a sheet of paper that nurses use to capture important patient information and stay organized. It contains sections for key areas like patient history, diagnoses, labs, medications, body systems status, and more.
In part 1 of this video series, Cathy walks through her Nurse’s Brain and how to use it. Using your Nurse’s Brain ensures a seamless end-of-shift report—to your CNA , other nurses, and the doctor or hospitalist . In this video, Cathy explains how to give a good nursing handoff report and improve your nurse-to-nurse communication.
Download Cathy’s Nurse’s Brain template
What is the end of shift report for oncoming nurses?
An end of shift report is a detailed record of a patient’s current medical status. It’s written by nurses who are finishing up their shifts and are then given to nurses who are beginning their next shifts. It should include the patient’s medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
Why is the end of shift report for oncoming nurses important?
An end of shift report allows oncoming nurses to understand the medical needs of their patients and provides a picture of a patient’s recovery or decline within the last several hours. By knowing what has previously occurred in a patient’s treatment plan, nurses can continue to provide care that will result in a positive outcome.
How to use your nurse’s brain to give report to the oncoming nurse
At the end of your nursing shift, you’ll have a short window of time to give a report to the oncoming nurse. During this transfer of responsibility, the oncoming nurse needs to know the most important information about your patients, so it’s your job to give a concise, organized report on each of them. The amount of time you have for each patient's report depends on where you work and the nurse to patient ratio, but it's usually around 5 minutes per patient.
Your Nurse's Brain can function as a nursing handoff report template. If you have kept track of this information using your Nurse’s Brain, it’s easy to quickly transfer the knowledge at shift change.
What to cover in your nurse-to-nurse handoff report
- The patient’s name and age
- The patient’s code status
- Any isolation precautions
- The patient’s admitting diagnosis, including the most relevant parts of their history and other diagnoses
- Important or abnormal findings for all body systems:
- Respiratory: Is the patient on oxygen? If so, how many liters per minute are they getting?
- Cardiovascular: Is the patient on telemetry? Are they on a cardiac drip or heparin drip?
- Neuro: What is the patient’s level of consciousness?
- Musculoskeletal: Is the patient mobile or bed-bound? Can they get up independently or do they require assistance?
- Gastrointestinal & Urinary: Does the patient have any diet restrictions? When was their last bowel movement? Are they incontinent and do they have a catheter in place? What kind of catheter?
- Skin: Does the patient have any wounds or pressure injuries?
- Is the patient diabetic and are blood sugar checks required?
- What kind of IV access does the patient have? Are they getting continuous fluids? If so, which fluid?
- Is the patient on any antibiotics? Are they taking pain medication(s)? If so, when was their last dose?
- Does the patient require certain tests that day? Do they need wound care? Will the patient be discharged during that nurse’s shift?
What not to cover
There is such a thing as too much information. There are some areas you don’t need to give every detail on because they are either not relevant to the admitting diagnosis or something the oncoming nurse can easily look up. Using too much time on one patient will reduce the amount of time you have to give a report on the next patient. In your nurse-to-nurse report, avoid spending inordinate time on:
- The patient’s non-essential comorbidities. Sometimes patients have 30+ comorbidities and it would use all of your 30 minutes to talk about them.
- Every single medication the patient takes. Again, sometimes patients are on a laundry list of medications that the oncoming nurse can and will look up, so stick to the important ones.
- The patient’s specific labs. The oncoming nurse has access to these details if needed.
What if you are the oncoming nurse?
If you are the oncoming nurse, the best way to receive a report is to be punctual and focused. If you are late, it shortens the window of time that the departing nurse can report on patients.
Patient Involvement
There is good evidence that when a patient is involved in their care they experience improvements in safety and quality. Engaging with a patient and their families during a handoff with an oncoming nurse ensures a safe and effective transfer between shifts. It also gives nurses more time with the patients to answer questions and take care of any needs they may have.
Handoff communication in nursing
Giving a focused, efficient report is an important communication skill in nursing. Others will respect the care and organization you put in--which can improve your nursing relationships with coworkers. Giving a good report builds trust, ensures continuity of care, and improves patient safety.
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Full Transcript
In this video, I am going to share how to give a good report to the oncoming nurse.
As you know, you have a really short amount of time, 30 minutes max to give report for all your patients. And this could be three patients, four patients, five, maybe even more depending on where you work. You're going to have to be really focused and really concise on how you give report to the oncoming nurse.
If you are the oncoming nurse, be sure you get to work on time and be ready to get report at 7:00. I had a couple situations where I worked night shift and the oncoming day shift nurse would roll in around 7:07 A.M and get her coffee and chitchat and she really didn't come to get report until almost 7:15. And it's not really respectful and it really condenses that 30 minutes into a much shorter window to convey a lot of information. Just try to be respectful, get there early, get your lunch put away and just be ready to get that report at 7:00.
When you are giving report, what information is important to convey? Because, again, you only have about five, seven minutes per patient. You want to communicate the patient's name, their age, their date of birth.
You want to talk about their code status because if the patient were to code, right? Like have a cardiac arrest for the oncoming nurse, should they perform CPR or is the patient a DNR patient?
In addition, you want to let the oncoming nurse know if a patient is on contact, airborne or droplet precautions.
In addition, you want to explain the patient's admitting diagnosis and maybe briefly describe their hospital stay and what the status is regarding that admitting diagnosis.
In terms of the comorbidities, I wouldn't go into a lot of detail about those. Some of the patients we get have like 30, 40 comorbidities. If you talk about all of those with the oncoming nurse you're going to be there for the whole 30 minutes on that one patient. If some of those comorbidities are really relevant to the admitting diagnosis, then definitely share that. Otherwise, I wouldn't really go into a lot of detail about that.
Then you want to run down all of the body systems and give the relevant information that you need to give to the oncoming nurse.
So, respiratory. Is the patient on oxygen? If they are, how many liters per minute are they getting?
Cardiovascular; is the patient on telemetry? Are they on a cardiac drip or a heparin drip? That's going to be important information to convey.
Nervous system; what is the patient's level of consciousness? Are they alert and oriented times four or are they confused? Definitely share that information with the nurse.
What about the patient's mobility? Are they bed-bound? Do they have any kind of paralysis? Can they get up independently or do they require assistance? Those are going to be important things to convey.
In addition, gastrointestinal and the urinary system. Let the oncoming nurse know if the patient is incontinent and whether they have a Foley catheter in place or maybe a condom cath or a Purewick. If you know the patient's last bowel movement, that's always really helpful information for the oncoming nurse to know.
Skin; does the patient have any wounds or pressure injuries? Pressure injuries is the current term for a pressure ulcer or a bedsore is what it was called previously. But if the patient has any wounds or pressure injuries, you definitely want to convey that to the oncoming nurse. And if there's any wound care that is required in the coming shift then definitely remind the nurse of that as well.
If your patient is diabetic definitely tell that to the nurse and let her know that blood sugar checks are required.
Then you want to let the oncoming nurse know what kind of IV access the patient has. Is it a peripheral line? Is it a PICC line or a central line? Are they getting continuous IV fluids and if so, what is it? Is it normal saline, 75ml an hour? You want to give all of that information.
In terms of medications, you're not going to run through all of the medications that the patient needs to get. But I would review any antibiotics that the patient's on. In addition, I would also review any pain medications that the patient takes and when you gave the last pain medicine and when they're due for their next dose, if that's appropriate.
And then you want to convey the plan for the next shift. If you're night shift and you're handing off to a day shift nurse, you want to make them aware if the patient's getting any kind of procedures. Like a CT scan or an MRI or if they're having surgery. Definitely want to give the nurse a heads-up about that.
If the patient requires wound care, you want to let them know about that.
If the patient's going to discharge that day or be transferred to a skilled nursing facility, definitely communicate that so that the oncoming nurse knows what the plan is for the patient. And then that's pretty much it.
As far as other details, like specific labs and some of those comorbidities and other medications, the nurse can look up that information. You're really going to focus on those essential things when you are giving report to a nurse.
Hopefully, this video has been helpful. It takes some practice to get really good at report but I know you can do it. If you can, have your Nurse's Brain in front of you to keep track of stuff. But again, don't go through everything. Just focus on those few vital pieces of information that I shared in this video.
If this video's been helpful be sure to like, subscribe, leave your comments here and I look forward to seeing you soon. Thanks so much for watching!
Cathy Parkes
6 responses.
March 01, 2022
Thank you. Your videos are so helpful.
January 17, 2022
Great video. Thank you
October 29, 2021
Thank , it helps me a lot .
June 02, 2021
Thank you so much for such details on a successful hand-off shift report. I really appreciate the information and it’s going to make me a better nurse reporting off. I have heard whispering from some peers that I wasn’t giving enough details or good reports. This is a great learning tool and will truly help me shine. Thanks.
November 09, 2020
I have read this every shift during my residency, it always centers my attention and allows myself to transition into the oncoming role of care. I really appreciate the time and dedication you put into these videos. Everyday you make the world a better place! Jordan RN. CVPCU
catherine ofeinmun
August 11, 2020
You are a wonderful person Cathy. Please keep up with the good works. I can’t wait to buy ur flashcards for my fundamentals of nursing because i believe it will really help. Thanks so much
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My RN Report Sheet
Nursing Handoff:
an essential yet terrifying part of your job as a new nurse.
If you have ever felt overwhelmed, unprepared, or straight up shoook during handoff, you are not alone.
Giving a thorough and accurate report during change-of-shift is critical for patients, but it can give any new/student nurse anxiety beyond belief. In my early nursing days there were times I:
Cried after giving report because my oncoming nurse called me out for not knowing details
Had eyes rolled at me for taking too long giving report
Forgot essential bits about my patient while rushing through report for so-called eye rolling
Been peer pressured to not do it at the bedside
Stayed an extra hour(+) into the next shift to sort out whatever my oncoming nurse thought was incomplete
Sounds fun, right? After a long 12 hour shift overnight working your tail off, having your report torn into shreds makes your feel like garbage. Handoff can truly feel like the most daunting part of your day as a fresh nurse.
Cue Report Sheets AKA your “brain”. They are common in nursing, especially when you are just starting off, to organize your thoughts and tasks throughout the shift. Yes, it’s called a brain sheet because literally, this becomes your BRAIN.
Print it out, attach it to your care plans and use it as your guide throughout your shift. When change-of-shift comes you have everything you need to know about your patient in an organized fashion. It gets you through your shift- from the moment you get report to the moment you give it.
So here it is, my sacred report sheet. It’s the method I have used for years with patients and what I offer to my student nurses when they are starting clinical.
Download my Report sheet as a PDF HERE
If you are a little confused, keep scrolling for clarification on abbreviations and formatting.
Basically, I organize my template into sections starting at the top with the most important safety information. I then go down in the way report is typically given/received: chief complaint, history of present illness (HPI) and past medical history (PMH). That then takes you to the head to toe with reminders in each system of things to cover & look out for.
On the right side I keep shift organizing topics: the patient’s plan, test/procedures, anticipated discharge, goals and med passes. At the bottom I always leave space for notes, because at some point you will need to keep track of new orders, critical values, changes in patient status, reminders for charting, education, or hey, even a reminder for you to go drink some water.
Receiving and giving report is an art that will only be mastered with time, organization and practice so do not get discouraged! I hope this template can help organize your thoughts for each patient and remind you what is necessary to ease the handoff process.
If you are a student or new nurse, please reach out with any questions, thoughts, or ideas. I have said it before and I will say it again: there are few career choices as selfless, honorable, and rewarding as becoming a nurse. Keep it up and just know there are millions of nurses that started exactly where you are right now.
Drop me a line in the comments or find me on social media, I’d love to hear from you!
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Nursepective
Empowerment in Nursing and Beyond
A Budding Nurses’ Guide to Nursing Report Sheets: With Free Customizable Template
February 27, 2022 · In: Nursing School
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.
What is the purpose of a nursing report?
A nursing report is a system by which nurses communicate important patient information. This communication allows nurses to know their patient's conditions, medications, and treatments. The nursing report also alerts nurses to any potential problems that may need to be addressed.
Why is this important?
The exchange of information between nurses is critical for the safety and well-being of patients. Nursing report helps ensure that all nurses are aware of changes in a patient's condition and provide timely interventions if needed.
Why do nurses use report sheets?
A nursing report sheet is a form that nurses use to document the care they provide to their patients outside of the EMR. Report sheets or brain sheets help nurses keep track of patient information, such as medications, treatments, and vital signs. They also help nurses communicate with other healthcare team members about their patients' status.
If you are like me, you probably have too much going on during your shift and many patients to take care of to remember every single thing during shift change.
Admitting and discharging patients in a single shift with multiple orders coming through within the hour, I know I cannot rely solely on my brain to remember everything, and I know I am definitely not alone on this table. This is why nurses need their nurse brain sheets for shift reports.
What should be included in a nursing report sheet?
The answer to this question depends on you as a nurse and the specialty you are working in. As a nursing student, a new nurse, or an experienced registered nurse, your sheet template should be designed according to your individualized workflow and specialty area.
Medical-surgical nurses' report sheets will have similar things to an ICU nurse's report sheet, but there will be some differences due to the difference in their specialty.
With that said, irrespective of your specialty and your personal preference, there are some key things that you should include on your report sheet to ensure patient safety and efficiency at work.
A nursing report sheet should include the following information:
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.
Current medications
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.
Why do you need a nursing brain sheet that works for YOU
When you're a nurse, there are so many things to keep track of- from patient information and medication administration to treatments and notes. And that's not even counting the other tasks you have to juggle on top of your nursing duties. Finding a report sheet that is especially tailored to your workflow makes it easy to keep sane and easily find all the vital information you will be needing to properly care for your patients.
How can I make my own nursing report sheet?
There are many different ways to make your nursing report sheet. You can find templates online or create your custom design.
Here are some tips on how to make a report sheet that works for you:
● Ensure the layout is easy to read and includes all the information you need.
● Include headings for each section, so it's easy to find information quickly.
● Use clear and concise language, so everyone who reads the report can understand it easily although no body might but just in case.
● Use diagrams such as the fishbone for visualize info like your lab reports, if needed.
● Print out a copy of the report sheet for every shift so you have it handy when you need it.
● Creating your nursing report sheet can be a great way to improve communication and patient care. By taking the time to create a sheet that works for you, you'll be able to work more efficiently and effectively during your shifts.
Is it important to write a nurse report?
Nurse reports are an essential communication tool between nurses, doctors, and other healthcare professionals. They can also help document the care that has been provided to a patient. Plus, they're just good for creating a record of what happened during your shift. It is therefore important as it will not only make you efficient as a nurse and improve communication, but more importantly, it can help improve patient care and safety. Grab a FREE copy on this article.
How do I write a good bedside report?
Use a template as attached above where there will be all the critical information you will need to know on your patient, or you can follow the guide above to make one afresh on Microsoft Word or on Canva if you know how to use it. Alternatively, you can just write everything on a blank paper.
Can I use any report sheet I want?
Yes, you absolutely can as long as it makes sense to you. Feel free to use any template or format that works best for you. Just be sure to include all the pertinent information you need to provide excellent care to your patient in an easy-to-read format.
What should I include on my report sheet?
The layout of your report sheet will vary depending on what information you need to track. Still, standard sections usually include patient name and ID number, important patient specific info, shift info, doctor's orders, medications and treatments given, vital signs, observations, and diagnosis and many more. You can use the reference above or use the FREE nurse report sheet attached in the beginning of this post.
How do I organize my nursing reports?
Nurses need an efficient way to record not only what happened during each shift/patient encounter but also any additional details they may have learned throughout the day. The easiest answer to this question is, organize it based on what makes sense to you or what you can easily make sense of. Just make sure to include all the above pertinent info.
I hope this article has helped you understand the importance of nurse report sheets. From making sure everyone knows what is going on to using it to track everything that occurred during your shift, these forms are essential for any nursing team. Download this customizable nurse report sheet today and personalize its content according to YOUR needs instead of spending hours fumbling around trying to find just the right brain sheet online. Until we meet again on my nurse blog post, happy nursing!
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Download Brain Spreadsheet We've provided a ONE page downloadable Nurse's Brain document. However, some nurses use ½ page or ¼ page for their patients. Feel free to download this document and use it as-is OR make a copy and modify it to meet your needs. This Nurse's Brain is modeled on what Cathy used in a Med-Surg/Tele/Stepdown unit.
I’m going to show you examples of 20 of the 33 nursing brain sheets that are included in the database. 1. Handoff and Nursing Report Sheet This is the report sheet that my preceptor used to make me fill out prior to the end of each shift as a newbie.
For example, a nurse might have to test the patient’s blood sugar at certain times during the day. Your brain sheet will help you determine if the results fall within normal lab values. Some things you might find regarding ongoing patient care include: What dosages of medications need to be administered, and when
Nursing brain sheets go by many names. They are called report sheets, security blankets, flowcharts, to-do lists and everything in between. What are they exactly? Nursing brain sheets are those papers that have all of the information on your patient. You will have your history, diagnosis, meds, lab values, and so much more.
Brain Sheets - Nursing On Point Brain Sheets The documents below are a repository of “brain sheets” that may be helpful to you for organizing patient clinical data. Such documents are often especially helpful when you are giving and receiving report on patients to other nurses or healthcare professionals.
A Nurse’s Brain, also known as a nursing report sheet, is a term for a sheet of paper that nurses use to capture important patient information and stay organized. It contains sections for key areas like patient history, diagnoses, labs, medications, body systems status, and more.
Some hospital-specific protocols 1 patient Lots of details for nursing assessment Med-surg, with details about long-LOS patients Details about wounds Regular vital signs recording Nosocomial infection notations PCS pump notations Nice graphic for wound mapping Detailed notation of pain meds timings SBAR format 4 patients Very basic med-surg
They are common in nursing, especially when you are just starting off, to organize your thoughts and tasks throughout the shift. Yes, it’s called a brain sheet because literally, this becomes your BRAIN. Print it out, attach it to your care plans and use it as your guide throughout your shift.
A nursing report sheet is a form that nurses use to document the care they provide to their patients outside of the EMR. Report sheets or brain sheets help nurses keep track of patient information, such as medications, treatments, and vital signs. They also help nurses communicate with other healthcare team members about their patients' status.