Nursing Report Sheets: The Nurses’ Tool For Every Situation

by | Oct 9, 2018

Nursing Report Sheets

A nursing report sheet is a paper template that a nurse uses throughout the day to keep track of what is going on with his or her patients. At the beginning of the day, a nurse might start a report sheet based on the information the leaving nurse provides. Throughout the day, that same nurse might have sheets specific to his or her patients or department. Some will choose simple sheets, while others prefer to have every detail noted. That’s a matter of personal preference, and we will be providing some of the best sheets for every nurse, no matter the style of work or specialty.

Nursing Brain Sheets

nurse with stethoscope

These nursing report sheets, also called “brain sheets,” include crucial information such as a patient’s allergies, medical history, diagnosis, consults, attending physician, medications, lab results, and vital signs. The following are some of the many other bits of information that can be added as well:

Brain Sheets

  • Insulin coverage and blood sugar levels
  • Telephone orders from physicians
  • Lab values sent from the laboratory
  • Notes to remind you what needs to be done for a patient on your shift
  • Intake and output
  • Tips about things you want to remind the nurse taking over later

Benefits of Using a Nursing Report Sheet

Nursing-Report-Sheet

The most significant benefit of using nursing brain sheets is that you have immediate access to information about each of your patients. For example, if your patient’s physician asks for information about the patient’s PT/PTT, you merely need to glance at your report sheet to find out the answer and relay it to the proper person. There are other ways a nursing report sheet can be helpful, however.

Nursing Report Sheet

  • It gives you an easy way to determine everything that needs to be done before you complete your shift. You can take a look at the sheet you’ve built for each patient to remind yourself of what is a priority and what needs to be done later to ensure you are giving the patient great care.
  • It offers a way to make your charting more efficient and accurate. As you add things to your sheet over the day, you will be able to complete your charts at the end of a shift smoothly. When you work with a handful of patients on an average day, things can get mixed up. Your brain sheet prevents you from making errors or forgetting to chart essential things.
  • It makes it easier to differentiate between what happened with one patient and another. It can be challenging to remember the history and diagnosis for all of your patients without getting something shifted. With the help of your nursing report sheet, this will be a thing of the past.

Types of Nursing Report Sheet Templates

one of the report sheet templates

There are dozens of types of nursing, which all require different amounts and kinds of information. A charge nurse is going to have different daily tasks than an ICU nurse. The same goes for a nurse who works out of the emergency department and one who specializes in cardiac nursing.

Some nurses like to take pages and pages of notes, while others prefer to fill in a few boxes and move on. The point is that one nursing report sheet might be ideal for one person, while it’s useless to another. That’s why we wanted to offer a few of the options you have and explain what makes each unique.

The New Shift Report

At the beginning of your shift, you will be receiving copious amounts of information about your patients from the nurse who is headed home to rest. Remembering everything that this person says is challenging, and in cases where you have many patients, it can be impossible. Several things, such as these listed, might be included in a handoff or start-of-shift report:

nurse writing a form shift

Shift Report

  • Neurological state, including information about speech clarity, extremities, sensation, ability to follow commands, and orientation
  • Respiratory state, including lung sounds, O2 delivery, and average stats
  • Skin state as related to surgical sites or dressings to change
  • Pain status, including reasons for pain, pain levels, and pain control methods
  • Cardiac state, including blood pressure trends, medication, edema, fluids, and pulse location
  • Genitourinary status, including methods and schedules for dialysis
  • Gastrointestinal state, including blood sugar levels, diet, and presence of vomiting or nausea
  • Plan for a patient, with information regarding procedures coming up, family dynamics, and ideas for discharge

You will likely not need to fill out every section for each patient, but a template that includes all of these can be used for any patient, rather than having a specialized sheet solely for start of shift information. An example of an excellent shift sheet can be found at www.NRSNG.com, the first sheet in the list.

Simplified Nursing Report Sheets

If you are the type of nurse who prefers to only take down the most critical information, without all of the superfluous details, there are plenty of charts out there for you, too. If you want to build one on your own, we have you covered. Here are some of the things you might want to include on your mini nursing sheets:

  • Patient name
  • Attending physician
  • Medications
  • Blood sugar levels
  • O2 levels
  • IV fluids
  • Pain medications
  • Tests
  • Other important notes

The Patient Simple Nurse Task Sheet (number 4) or Patient Simple Tele Sheet (number 3) are excellent options for those who prefer a minimalist report sheet style. Other simple sheets from that website include All the Boxes and the Vertical Nurse Brainsheet with Assessment Diagram. You can download a three-patient-per-sheet mini report sheet as well. If you prefer, build your own with all the information that matters to you.

Detailed Nursing Report Sheets

In contrast to those who prefer a simple brain sheet, there are those who like to jot down all of their thoughts throughout the day. Many nurses who fall into this category appreciate having more space available to take notes and less space to keep track of assessment information.

The Whitespace Nursing Assessment Sheet (number 20) is an excellent example of this idea. The top has the information about the patient, while the edges leave room for information about labs, IV fluids, and other things of that nature. In the middle of the page is a large white area where you can keep note of anything that seems relevant.

A slightly different option is number 14 (Boxes, Boxes, Boxes) on that same website. It has many of the same features as the one above but with more space for each item that is important. It also includes a box marked “password,” which is hugely beneficial if the patient prefers only people who know a specific phrase are allowed to enter the room they are staying in.

Postpartum Brain Sheets for Mother and Child

nurse taking down notes

Whether you are doing rotations in postpartum or are working there as a specialty, there are many unique things you need to keep track of. You will need to be aware of the mother’s temperature, pulse, blood pressure, and blood sugar. However, it’s also important to assess the baby on a regular basis, keeping track of skin color, temperature, pulse, and feedings. The best nursing report sheets for this will have both patients listed so you don’t have to thumb through additional information.

Some of the best sheets for this situation are located here and here. You can also look at Postpartum Nursing Brain Sheet (number 7) and Mom-Baby Brainsheet (number 9).

Charge Nurse Brain Sheets

Every nurse has a whole lot on his or her plate, but for nobody does that ring truer than for those who are charge nurses. The typical charge nurse treats patients but is also tasked with supporting and supervising nursing staff. This means that daily duties include typical nursing tasks, managerial duties, and administrative responsibilities. Because of this, it’s no surprise that charge nurses need a little help remembering everything they need to do during a specific shift.

charge nurse at work

When it comes down to supervising patients of nurses on the charge nurse team, there may be little need for as much detailed information as there would be for the nurse doing most of the treatment. As such, many charge nurse brain sheets are going to be broken down into patients or rooms with each only taking up 1/4 or 1/3 of the sheet itself.

The following bits of information, by patient or room, are included in this example:

  • Basic information, such as name, age, diagnosis, and date of admission
  • Allergies, codes, cardiac notes, neuro notes, and IV needs
  • Information regarding GI, GU, labs, respirations, and skin issues
  • Daily goals and tasks that need to be completed
 The actual information will vary based on the department and needs of the patients.


Situation Background Assessment Recommendation (SBAR) Sheets

communication between doctors and a nurse

Some hospitals and medical facilities choose to have a communication method that is standardized and used across all members of the healthcare team. One of the most common techniques is the SBAR. It offers information on how information is structured, how it is communicated, and what it should be composed of. If this is a technique used by your facility, the good news is that there are many report sheets that take this into account.

This type of sheet is set up in a specific way. It starts at the top with the situation, moves into the background, uses the assessment to fill most of the sheet, and ends with recommendations. Here is what you can expect at each point in the technique:

  • Situation – This is an area that includes information about what is currently happening. It gives necessary information to the next person on shift, including the patient name and why he or she is there.
  • Background – Next up is the background area. This is going to detail relevant medical information. There might be boxes to check for whether the patient is a smoker, struggles from drug abuse, or has a form of dementia. It will also list any tests that have been done on the patient.
  • Assessment – There is a lot of information here, broken down into sections like cardio, IVF, neuro, and pain level. This is the meat of the sheet and explains everything the next nurse is going to need to know, whether that is to watch for wounds or expect to get back CKMB labs.
  • Recommendation – The final area of the nursing report sheet, it will list upcoming procedures, consults, and other pertinent information. If the patient is going to be discharged, it will explain whether he or she is leaving for home, rehabilitation, or a home health center.

Choosing the Right Brain Sheet for You

Everyone is different and will have unique needs when it comes to brain sheets, charting, and patient care. We hope this article will give you a place to start in choosing the method that works best for you. Whether you build your own sheet, use someone’s template, or buy a hardcopy version of nursing report sheets, each can offer you a bit more success as you go through your day.