FREE 3+ Nurse Report Sheet Samples in PDF

Nurses are known as the backbone of the medical community as they take care of the patients during the doctors’ absence and are required to submit an informative history of care and injury by accomplishing a nursing report. It is necessary for a nurse to complete their nursing reports because doctors utilize them to keep track of the patient’s progress report to determine whether their treatment plans are effective or not once it has been prescribed. With a nursing report sheet or template, nurses will be able to easily keep track of the progress of each of their patients.

3+ Nurse Report Sheet Samples

1. Nurse Report Sheet for Newbies

2. Nurse New Shift Report Sheet

3. Nursing Report Sheet

4. Nurse-To-Nurse End of Shift Report

What Is a Nurse Report Sheet?

A nursing report sheet is a ready-to-use template utilized by nurses at the beginning of their shifts when they get another nurse’s report who is ending their shift. This report worksheet helps nurses in keeping track of their patient’s progress which also contains critical information about their patient’s medical history, diagnosis, allergies, consults, their attending doctors, lab results, vital signs, medication times, and more.

How to Write a Nursing Report

Producing an effective nursing report enables a smoother shift transition for the nurses while efficiently monitoring the progress of their patients. A nursing report sheet is used to access a shift report which contains valuable information about every patient under their care. The report sheet provides details in each patient’s name, the reason for their admission, and other relevant information such as medications for the day, nutritional status, lab reports, code status, vital signs, and more.

Step 1: Collect Subjective Evidence from a Patient

Once you have recorded the date, time, and the patient’s name, you can start your nursing progress note by collecting subjective evidence which includes the patient’s pain level, the reason for their admission, and other concerns they might have. If in the proper situation, try asking any family member or friend escorting the patient if they have observed anything related to the patient’s health.

Step 2: Keep a Record of the Information and your Assessment

After communicating with your patient, collect objective data to put in your notes which includes the patient’s observable symptoms, vitals, and test results. You also have to include your assessment which refers to your observation of the patient’s appearance, symptoms, and attitude after their medication was prescribed when their admission started.

Step 3: Construct a Care Plan

The care plan on your progress notes contains the course plan that the doctor has created to provide the patient. If the patient is going to take an MRI scan, it should be mentioned in your notes or report. You also have to include important and relevant information about the patient’s reaction to your healthcare plan.

Step 4: Include Additional Notes for Additional Facts

This section includes a variety of information but it mostly contains details on any additional facts related to the care that the patient has received during a nurse’s shift. It includes details on the time they administered medication to the patient, requests they might have, and other observations of their condition.

FAQs

A nursing report sheet is a template that nurses can readily use to keep track of their patient’s progress as well as their observations during the patient’s treatment. This document contains essential information about their patients such as their diagnosis, medical history, details on their attending doctor, medical consultations, individual treatment plan, and other observations on the patient’s treatment response that a nurse has obtained during their shift.