Signature Block Nursing Visit Report Form Made Easy

Nursing 100 fill in worksheet form

hello I'm a nursing people it slays welcome back to my channel today we're gonna talk all about the nursing brain and the report sheet something that I have had so many student nurses and people have precepted and just new nurses asked how on earth do I keep track of this chaos when you have five or so patients it gets to be a lot but having an organized report sheet is going to save your life so if you're like me you have to write absolutely everything down otherwise it's not going to get done and I finally come up with a way that kind of condenses all that information into an organized pallet that I can then work off of and cross things off when I'm done because I'm also super type-a and I love crossing things out so if you're looking for something that can kind of give you a overview in your entire day you can hold up to four patients on one piece of paper if you have five you kind of have to staple two together and you get to cross a lot of things off and this is for you okay so here's the basic overview of my report sheet I have a typed one that I actually use at work but this is the same general idea so on the top left I'm going to put the date of today and then on the right I'm gonna put my phone number so we have phones on my unit if you have your pager number and you maybe switch those out you could put that here the next is going to be the patient's name I always do their last name first followed by their first name since that's how all the medical documents always have it and I usually capitalize their last name just so it stands out a little bit more on the right hand side I'm going to put their age and their gender below that I'm gonna put their diagnosis of why they are currently admitted to the hospital so that's not going to include their past medical history it's just going to include what is bringing them in this time and maybe what's keeping them here depending on if it's been a long admission below that I do the pertinent history so this if it's a complicated patient isn't going to be you know all 20 diagnoses that this person has acquired I'm going to do the ones that are super important surgeries that they've had recently that might affect their care things that really stand out that I would want to remember and then below that I'm going to put their contact the precautions that they're on while they're in the hospital so that's going to be stuff like contact precautions droplet precautions I'll put when they got swab for whatever it was and what they swab positive for that's also where I put seizure precautions and aspiration precautions next is the vital signs column chart at the top I will cross that off when I've charted that patients assessments and then nine one and five or when I get their vitals again when I've gotten that patient's vitals at those times I cross it off monitors are what's monitored on them a cardiac monitor is CR pulse ox is Oh two I then I'm going to put their oxygen parameters or any vital signs parameters that are important to the patient so if this one it would be you need to give them some kind of medication if their systolic is over 120 below that I'm going to do how much oxygen they are on this would be if they're on nasal canula CPAP BiPAP anything like that and then what you want their oxygen percentage to stay above so this one would be ninety percent in the diet category I'll put if they're NPO what kind of diet they have if they are eating this would also be like tube feeds what their tube feeds are running at and what their tube feeds are running through this is a good place I also usually put if they're on a fluid restriction I'll put it in the diet category the next column is going to be their IV and that's where I put any lines or I like IVs that they have so PICC lines peripherals and I also put when everything was changed this one here you can see it's a right double pick and then I usually do with I put the lumens so like G would be gray and the gray has running through it and the red is hep locked and then but down here I always like to know when my caps were changed and when the dressings were changed so I'll say that the gray cap was changed on a certain day and the dressing was changed on a certain day I don't do when my lines were changed I just look at that when I go into the room eyes nose is the next column this is one where I will put you know what their total fluid goal is if they're if you're titrating fluids I will also do if they are weight up or weight down that's something that's important to my population since little so and I always like to know you know what were they compared to yesterday so in this case they would be up point three kilograms from yesterday lDA's all their lines drains I usually put here like their G tubes their J tubes their chest tubes if they have a PCA I would probably write that here anything that is sticking out of them that I would like to know wound vacs jacks like JP drains Penrose drains anything like that the star is just things of note that are a little bit different that I want to make sure to remind like keep in mind and remind the next shift for sure what it have so like this patient was tachycardic all day with the heart rate in the 130s to 140 s their blood sugar was elevated it's a nice place just for me to kind of jot down like these things were kind of weird also if the team comes by I can just look at this column and be like hey this is you know their vitals and a reminder to myself that they have a dressing twice a day so just like a little chunk of you should really know this drug calculation wait is next that's their weight while they're here their last weight is next to it that's less important for adults but for kids you always know know what they were compared yesterday compared to their overall weight then I write out every hour that I am going to be there so and this is going to be my legend for what I need to get done every hour and as I go through I'll cross it off but I'll only cross off that hour when I've accomplished everything from it so if I'm working a 12 hour shift this is what it will look like I circle the hours that I have med passes I underline the hours that I have feedings or something to do with their food and I star the hours when they have a asked to do such as a dressing change a lab draw anything that's time-specific and a task and then when I've done all of those and I've charted on that hour I'll go through and I'll cross it off so then I can keep track of what I'm up to date with next to that I write all the fluids that they have going through their line so that would be PCA any drips any fluids if you're working in an ICU obviously it might look different because you might not have enough room right there I usually can fit four to five drips going and I work in a step-down unit all right below this Oh like my hair we're going to do I have a general info on the left and then I have a to do area on the right so the general info area I'm going to put things that I are pertinent to the patient but didn't need to be in that block up above I start with their allergies if they have any and I usually underline it just so it stands out I also usually highlight it in pink because why not and if I know what the reaction is I will include that as well so here like I said I just put a ton of stuff about what the patient likes like do they like watching The Lion King do they like it when you know you play a certain type of music for them what general preferences you can put the phone number of a contact information there you can do you know this is how they ambulate the best they prefer the bedside commode rather than going to the tote you know toilet so just things like that sensitivity to narcotics that's a good one to always know like how do they react to all of those things how do they prefer to take their medicine just general things that you would kind of want to know you could also do their extended history here sometimes if it's a patient within a ton of medical history I will include it over on that side you also see I did PNP dq2 so just kind of reminding myself that they get P MPD every two hours on the to do is this is everything I need to that wasn't included up on my hourly log and some of it I even double due just to kind of clarify to myself below so I need to write their care note I need to feed them at 811 2 & 5 they have a bath at 10 a.m. we'll do a lab draw it so you can also see that these things down here have the Stars up them up above so it's a kind of a double reminder for me or it reminds me what on earth I have to do sometimes I write the Stars and I totally forget what I was actually supposed to do I also do notes I need to do clarify with the team if I need to document a neuro assessment every few hours if I need to document like a pca amount every few hours and a pain score I'll write that down there pretty much if I don't write it down I don't necessarily remember it so I write everything down up there and then below that I usually do my second patient so this sheet can hold up to four patients because you could do top and bottom front and back you could also do one page for like one patient if you had a ton to write so that's the basic overview of my report sheet you can tweak it however you want like I said before I work on a pediatric floor we my she does kind of tweak towards what I want to pay the most attention to in that population however there are a ton of different ways you can organize it I've had when I worked on the adult GI population my work had a totally different focus than some of the things that I focus on in mind if you work in an ICU you're probably going to want to tweak it even more you'll have less patients so you could even take up that whole bottom half of the page with other information you're gonna have a lot more drips lines parameters and prm's that you're gonna want to keep track of so I would just put that down below so yeah that's not an exact thing to coffee off of but I hope it gives you some form of an idea of how to give an organized report what a report sheet can do for you and how it can help you organize your day alright if anybody has any questions or any ideas on what their favorite part of their report sheets are let me know down in the comments and we'll see you next time I you