The Ultimate Nursing Report Sheet Guide - Free Downloads!
As a nurse, you know the importance of clear and concise communication, especially when it comes to patient care. Nursing report sheets play a vital role in ensuring seamless handovers between shifts, ultimately contributing to improved patient outcomes. However, navigating these sheets can sometimes feel overwhelming, especially for new nurses.
What are Nursing Report Sheets?
Nursing report sheets are standardized forms used to document a patient's condition, including vital signs, medications, treatments, and any relevant observations. They serve as a communication tool between nurses, ensuring continuity of care throughout the patient's journey.
Benefits of Using Nursing Report Sheets:
- Improved patient care: Clear and accurate documentation facilitates better communication and collaboration among healthcare professionals, leading to improved patient care.
- Enhanced safety: Reporting potential risks and concerns helps identify and address issues promptly, ensuring patient safety.
- Reduced errors: Standardized formats minimize the risk of errors and omissions associated with free-form documentation.
- Increased efficiency: Pre-structured templates save time and improve efficiency during shift changes.
Essential Components of a Nursing Report Sheet:
- Patient demographics: Basic information like name, age, diagnosis, and admitting date.
- Vital signs: Temperature, pulse, blood pressure, respiratory rate, and oxygen saturation.
- Medications: Current medication list, including dosages, frequencies, and routes of administration.
- Treatments: Treatments received and planned, including interventions like dressing changes, oxygen therapy, and suctioning.
- Laboratory and diagnostic reports: Summary of recent tests and results.
- Neurological status: Level of consciousness, orientation, and any neurological deficits.
- Pain assessment and management: Description of pain, pain score, and current pain management strategies.
- Fluid intake and output: Total intake and output for the shift.
- Activity and mobility: Level of independence and assistance required for daily activities.
- Skin integrity: Assessment of skin condition and any pressure injuries.
- Nutritional status: Dietary intake and any nutritional concerns.
- Discharge planning: Current discharge plan and any anticipated needs.
Tips for Using Nursing Report Sheets Effectively:
- Complete the sheet comprehensively and accurately.
- Use clear and concise language.
- Document all relevant observations and concerns.
- Proofread the sheet carefully before handing off to the next nurse.
- Ask questions and clarify any uncertainties.
- Utilize standardized abbreviations and terminology.
By mastering nursing report sheets, you can enhance communication, improve patient care, and ensure a smooth and safe transition between shifts. Remember, accurate and efficient reporting is not just a good practice, it's a vital aspect of providing quality patient care.
10 Free Nursing Report Sheet Downloads
Our report sheets are used extensively throughout health systems across the country.
- Download and print PDFs, or edit in Google Docs/Microsoft Word.
- 1-4 patients per sheet, with portrait and landscape options.
- SBAR and Brain format: Perfect for Med-Surg, ICU, Tele, Step-Down, and ER units.
1. Full-Size SBAR Nurse Report Sheet
- Perfect for new grads and nursing students
- Fly through report by circling options instead of writing everything
- 1 patient per sheet
- SBAR format
- Great for all units
2. Brain Nursing Report Sheet Template
- Brain format
3. ICU Nurse Report Sheet
- Great for ICU
4. Mini SBAR Nursing Report Sheet
- 3 patients per sheet
- Quick report taking with circling options
- Great for med surg and tele units
5. 4 Patient Nurse Report Sheet
- 4 patients per sheet
6. Brain Nursing Report Sheet
7. 2 Patient Landscape Nurse Report Sheet
- 2 patients per sheet
8. 3 Patient SBAR Nurse Report Sheet
9. Full-size Nurse Report Sheet Template
10. History and Physical Template
- H&P format
- Great for nurse practitioners and NP students
Free Downloads!
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What is a Nursing Brain Sheet?
What is a nursing report sheet.
- How to Create
- Why They're Important
How to Read a Nursing Report Sheet
- Free Templates
Nursing report sheets, also commonly referred to as brain sheets or patient report sheets, are a valuable pre-made tool that nurses can use during a shift to keep important patient information. Truthfully, a report sheet is essential to making it through any shift.
Keep reading to learn more about nursing report sheets and get free templates you can use!
A nursing report sheet is exactly what it sounds like. It’s a customized sheet that contains important information regarding the patient and their medical history.
How Nurses Use Brain Sheets
Essentially, it is used to tell you the “down and dirty” about your patient. While every nurse should be going through their patient’s charts at the beginning of the shift and then throughout the shift, a nursing report sheet can be used to keep tasks and “to-do’s” organized.
How Hospitals Use Them
Some hospitals will have one nursing report sheet that will get updated each shift with a specific patient, while others hospitals will expect nurses to write a new report sheet with each shift.
Report sheets may go with the patient when transferred between units and are ultimately discarded when the patient is discharged.
How to Create a Nursing Brain Sheet
What’s included on a nursing report sheet varies depending on the hospital, unit, and the individual. It will depend on the expectations and policies of the hospital, and it’s important to speak to the nurse educator to determine the unit’s best practices.
Examples of what to include on a nursing report sheet include,
- Patient Information, including name, date of birth, room number
- Medical diagnosis
- Attending medical provider/coverage team
- Medication(s)
- Vital Signs
- Lab results, pending lab work
- Important procedures
- Family information
- To-do(s) for shift
- Nursing notes
Why Do You Need a Nursing Report Sheet?
Nursing report sheets can be the key to success when organizing information about your patients, especially if you work on a medical-surgical floor and have a higher patient/nurse ratio.
There are some key benefits of the nursing report sheet, including,
- Provide accountability
- Improving the safety of the patient
- Standardized report
- Fast access to patient information
- Keeping charting organized
- Organizing patient care
Some nurses will read it from top to bottom, while others will organize it based on systems.
Personally, most experienced nurses will organize their report sheets based on systems. Double-sided report sheets are even better, with one side having all the patient and medical information and the reverse side having an hourly checklist to help organize your shift.
To use a nursing report sheet, first start by including the information you can find in the chart, including basic patient personal information and health history. The remainder can be filled out during the shift report or after spending some time looking at the chart.
3 Free Nursing Report & Brain Sheet Templates
Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.
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Nurse's Brain, Part 1: What is a Nurse's Brain? (Free Download)
What is a Nurse’s Brain?
A Nurse’s Brain is a term for a piece of paper, or several pieces of paper, that we use to capture really important patient information to keep us organized.
There are sections for key areas like patient history, meds, body systems status, and more.
How do you fill out a Nurse's Brain sheet?
Having a Nurse's Brain for your patients will help you better prioritize your day. You might want to come in early to research patients and plan your day, so you can fill out some of this info before you get a report from the previous nurse.
It can also help you give more effective reports to your oncoming nurses, to your CNA, or to a provider. If you learn to do this well, your coworkers will respect the care and organization you put in to making their lives easier, which will improve nursing relationships with those coworkers. It also helps you take better care of your patient — because you are more organized and can clearly communicate what you need from the CNA, provider, or oncoming nurse.
Watch the video to see Cathy walk through each area of her Nurse’s Brain and tips on important things to consider for each section.
In the following videos in this series, she will talk about what to include and NOT include in your report to CNA, provider, and RN.
Get your free copy of Cathy's Nurse’s Brain!
Make a copy of this free resource, or you can download it as a PDF.
To edit this Google Doc, select File -> Make a Copy . To save it to your computer, select File -> Download and choose your format.
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. For Maternal Newborn, you would need something totally different. Check back for specialized Nurse's Brain documents to be added in the future.
Let us know in the comments if you found this useful and if you’d like to see more specialized Nurse’s Brains.
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Full Transcript: Nurse's Brain, Part 1: What is a Nurse's Brain? (Free Download)
Hi, I'm Cathy, and in this video I am going to talk about the Nurse's Brain, which is a term we use to refer to a piece of paper, or several pieces of paper, that we use to capture really important patient information to keep us organized. Having a Nurse's Brain for your patients will help you better plan and prioritize your day. It can also help you give more effective reports to your oncoming nurses, to your CNA, or to a doctor.
So, in this video, we'll talk about the Brain and then in subsequent videos in this playlist, I will be talking about how to give a good report to those different people on your team. So we have posted an example of a Nurse's Brain that I like on our website LevelUpRN.com. It is a full page for one patient which is what I prefer. However, I know some nurses like to have two patients per page, or sometimes even four patients per page where there's like a quarter of the page for each patient. You are free to, of course, do whatever works best for you. You can save this Nurse's Brain and modify it to your heart's content.
So the Nurse’s Brain that we've posted is really focused more on a MedSurg or Tele floor or even a Stepdown unit. So if you need a Nurse's Brain for like, a Maternal Newborn unit, then this probably is not going to work for you. However, if you find this is helpful, and you want us to make more Nurse's Brains for different types of units, we might be able to do that. Be sure to leave a comment, give us your suggestions and let me know how you like this Nurse's Brain. And as you use it, keep in mind that one thing you may want to do, which I always did when I worked on a MedSurg/Tele floor, because you may want to come in a little early before your shift, to look up some important information about your patients that you are assigned for the day. So you can kind of get a little bit of a head start and a better understanding of what you're walking into, versus walking straight into getting report from the previous nurse. So I know a lot of nurses do that. And nursing students do that as well. Some like to, you know, roll in right at 7am and just walk right into report. And if that's your jam, if that's how you like to do things, that's totally fine. It's like whatever works for you. But for me, like I said, I like to come in early, get a little organized, do some planning and fill out my Nurse's Brain as much as possible for the patients I'm assigned over the course of that day.
So now we will take a look at this specific Nurse's Brain. I'll talk about the different components and why I set it up the way I did.
Okay, so here is the Nurse's Brain that I have uploaded to our website. Over here on the left side is where we have the patient name, their sex, their age, their date of birth, their medical record number. This information can often be found on the patient stickers that are available on most units. So you can simply get one of those stickers for the patient and slap it right over this area. Instead of writing out this information.
Then here in the middle, we have the patient's room number, we have their code status, so whether they're full code, or DNR, which is always really important to know right off the bat, so that if your patient goes into cardiac arrest, you know whether to call a code and start CPR or to not do that. You need to really understand their preference.
Then we have what isolation precautions they're on. So if they're not on any, you can circle None here, we also have Contact, Droplet and Airborne precautions.
And then you can write down the patient's doctor, like their hospitalist. And then if they have a surgeon assigned to their case, or if they're, you know, a post surgery patient, then you can put their surgeon there. And if there are any other important team members that you need to capture, you can put it here on this line.
And then over here we have the patient's Admitting Diagnosis, what brought them to the hospital, their primary problem and why they're there. And then over here, we have Other Diagnoses and Patient History. So some patients come in with a huge laundry list of co-morbidities. So I urge you to really be selective here on capturing just the things that are going to be really important to know when you are caring for the patient. So just a little room here to capture that.
And then we have the Labs. So you'll definitely want to just look up the patient's labs. First thing to see if there's anything out of whack and if you're going to need to request an order for electrolytes or blood products or anything like that from the doctor. So I know some Brains have like that little tree that you can use to put in electrolytes and blood levels. I don't prefer that, but you certainly can put that into this space instead. So here we have the most common electrolytes, and then we have, you know, basically CBC levels.
And then the next area here is for Vital Signs. So depending on whether your patient's on telemetry or not, it really dictates how often you need to take vital signs. So if you need to take it like every four hours, you can put 8am here and then put in their vital signs and then put noon here, 12 o'clock, put in the vital signs, 4pm or 1600 and put in the vital signs. So it'll let you take a look here at their vital signs over time. So if you see their blood pressure starting to tank over the course of the day, that's important information and something you're going to want to notify the provider about.
Okay, then down here we have Medications. The way I like to organize my Nurse's Brain and kind of track that is, I circle the times where I have medications I need to give the patient. And if there are certain of those times where I need to give an antibiotic, I put like a little "A" by it or a little star, something to indicate that there's an antibiotic that needs to be given at that time, so I can make sure I hit as close to that time as possible, because antibiotics are more time sensitive. So if I have 9am meds I would circle 9am and then if I have 1300 meds, I would circle that. And again, if antibiotics are to be given at that time I put like a little "A" or a little star there. And then I don't like, write out all of the medications because for some patients, it's like 20 different medications. I can, you know, look it up on my Rover on my computer and easily take a look at that list there. So for my Nurse's Brain, I just need to know what times I need to give meds.
And then I also want to keep track of the as needed medications or PRN Meds. So, does this patient have pain medication available for pain? Do they have nausea medication as needed, anxiety medication, those type of things. And then I also keep track here about what time I gave them their last pain medication, so if someone's in a lot of pain and they're wanting their pain meds every three hours as it's available, I definitely keep track here of when I gave them their last dose.
And then moving on here, we've got their IV Access, like, do they have a PICC line? Do they have a peripheral line and where is it located? And how big is it? And then if they-- if the patient is getting continuous IV fluids, then I'll put what that is, such as normal saline, and at what rate they are getting those fluids.
And then down here, I will put in some important information about the different body systems.
So for Respiratory, if the patient is getting oxygen therapy, then I would select "Yes" here and I would put how many liters per minute they're getting through the nasal cannula. Or if they have a mask or some other thing I would make note here as well.
And then for the Cardiovascular system, I would note whether that patient is on telemetry or not.
And then in terms of their Neuro status, I would make mention here of their level of consciousness. This is something you'll probably need to get from the previous nurse. And then of course, do your own assessment and see if the patient is alert and oriented times four, or maybe it's three, maybe it's two, maybe it's one, maybe it's zero. You need to just find out, does the patient know their name? Do they know their date of birth? Do they know where they are? Do they know what month or year it is? Those are some typical questions that we asked to really gauge the patient's level of consciousness.
And then we have the Musculoskeletal system. And we really need to determine right off the bat, is this patient independent? Can they get up without falling and, you know, go to the restroom by themselves? Or do they require assistance? If they need assistance, is that a one person assist or a two person assist? Or are they on bedrest, so it's important to know that right out the gate so that you can set the bed alarm? If the patient should not get up independently, you need to make sure they have a fall risk light bracelet on, if they are at risk for falls, and you definitely need to ask for help, if needed if assist is required for that patient.
Okay, and then moving on to the Gastrointestinal and Urinary system. You just want to know the patient's diet. Are they NPO? Are they on a dysphasia diet? Or are they on a normal diet or diabetic diet, it's important to know that. It's especially important to know if they are on like fluid restrictions or salt restrictions. If your patient's on fluid restrictions, you're really going to want to coordinate with your CNA and make sure that you guys are tracking all the fluids that the patient is getting. Because patients often who are on fluid restrictions, they will ask for water from like everybody. So they'll ask the nurse, they'll ask the CNA, they'll ask the occupational therapist, they'll ask the wound nurse. They'll ask everybody. And so you just, you got to make sure you understand if they have any restrictions and definitely enforce those. Find out when their last bowel movement is. If you go up and down the halls at the hospital around 7:30 any morning, you can hear nurses asking that question up and down the hall to all the patients. So find out when their last bowel movement was. Find out if they are incontinent. So are they incontinent of urine, bowel or both? And then do they have a Foley catheter in place? Alternatively, do they have a condom catheter in place? A Purewick? Hopefully you guys are familiar with this. If not, it's a device that basically provides suction so if they urinate in bed, it gets sucked into the bedside-- a bedside container. So it looks like a--it looks like a giant tampon basically, but it doesn't go inside anything. It just kind of lays along the perineal area and sucks urine out. And then a Dignicare is named this but it's not too dignified. It's basically a fecal containment system. It's like a tube that goes up the patient's anus and collects fecal matter when they're having like a lot of loose bowel movements. Not very comfortable for the patient and often they don't work very well. Just my opinion.
Okay, and then over here we have the skin right? So you want to when you do your full assessment, you want to make sure you identify any wounds or pressure injuries that the patient has. So pressure injuries is the more accurate term we use today for what people previously called bed sores or pressure ulcers. I'm a wound nurse so I'm telling you right now, pressure injuries is kind of what we're trying to move the industry towards and that's what you'll hear more and more. So you'll, you know, capture any injuries they have here like, "Stage 2 coccyx pressure injury," that type of thing.
If your patient is diabetic or receiving like some kind of steroids and are needing to get blood sugar checks, then you can mention or track here whether they are getting basal correction, or they're getting nutritional coverage, and then you can kind of track their blood sugar levels here, again to see trends and just to track what those are.
And then, as you're getting report, you want to determine if the patient has any tests or procedures scheduled for your shift so that you can make sure to keep track of that.
And then are there any To-do items or Notes? Are there things that you need to get done or find out for the patient? You can track that here. And then when you go in to do your head-to-toe assessment on the patient, then this is the area I would use to track any abnormal findings. So I always track things that are out of range or abnormal. So I'm not going to write in here that they had normal breath sounds or normal heart sounds or clean and dry intact skin. But what I do use this space for is tracking things that are abnormal. So if I heard crackles in their lungs, if they have edema, if their bowel sounds are hypoactive, I put the unexpected findings down here at the bottom.
So this sheet really gives me all the information I need to really understand the patient's situation, be able to give report to other nurses or doctors and just really helps me stay organized with the day in terms of medications and such. So I hope that you find this helpful too. Definitely leave us some feedback. And in my next video, we will talk about how to give a good report, which is so important so stay tuned!
10 comments
Thank you, Cathy, this will help me to level up and give a better report.
Thank you so much, Cathy. I teach Med Surg theory & clinical for an undergraduate nursing BSN program and your nurse brain description was exactly what I was looking for to teach nurse brains. Much appreciated from our team :). Diana
Hi Kathy, Thank you for all your material and help during nursing school. Would you kindly create a Brain sheet for night shift? I’ve been trying to Edit this brain sheet, but it’s read only. :)
I love this thank you so much!
An OB/ PEDS Brain sheet will be nice. This is my last semester in the LPN program.
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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."
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 them 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
This sheet is perfect for those who like things simple. With a bit of guidance, it becomes a handy tool for MedSurg and Tele nurses who are often on the move. In the fast-paced world of MedSurg and Tele nursing, time is precious.
Nurses and nursing students need quick access to important information for efficient patient care, and this sheet does just that. It makes managing patient data and tasks easier, helping nurses and nursing students stay organized and responsive in busy clinical settings.
For nurses and nursing students in these fields, this sheet is a valuable resource that simplifies daily tasks and improves the quality of care they provide.
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 would be a great one for a nurse that has a flow and just wants a simple push to stay a bit more organized.
It's a great tool to simplify your daily nursing tasks and keep things running smoothly.
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.
In the fast-paced world of nursing, nurses often face a complex array of tasks and information. This "brainsheet" becomes a lifeline, helping us navigate patient care with precision.
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, assessments, 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 clinical.
9. Mom-Baby Brainsheet
As mentioned earlier, not being an OB nurse I’m not sure I can fully appreciate everything that is on this page . . . but I must admit it does seem impressive.
To give you a glimpse, I've included a compact screenshot of this page. It's evident that this brain sheet holds substantial potential for OB nursing clinicals, and I'm excited to witness the positive impact it can have for you!
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 has that the other does 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
If you work on a cardiac or post-catheterization procedural floor, this sheet is made just for you. It's a specialized tool designed specifically for cardiac nurses. It includes helpful reminders and dedicated spaces for cardiac-specific information like EKG readings, medication schedules, and post-procedure care details.
This sheet streamlines your work and helps you provide excellent care to cardiac patients. It's like a reliable friend accompanying you on your journey in the field of cardiac nursing.
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 who 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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Nurse Brain Sheet
Optimize patient care with Nurse Brain Sheet – streamline information, enhance communication, and boost efficiency in healthcare settings.
By Bernard Ramirez on Aug 08, 2024.
Fact Checked by Ericka Pingol.
What is a nurse brain sheet?
A nurse brain sheet, also known as a nursing report sheet or a patient report sheet, is a comprehensive document used by healthcare professionals, primarily nurses, to record and communicate essential information about a patient's condition, treatment plan, and ongoing care.
These sheets are a centralized location for documenting vital patient details, allowing nurses to stay organized and ensure continuity of care during shift changes, transfers, or handoffs. Nurse brain sheets typically include sections for patient identification, admission information, vital signs, medications, treatment plans, assessments, lab values, and any additional relevant notes or observations.
Nurse brain sheets are particularly useful for nursing students and new nurses. They provide a structured format for documenting and communicating patient details during shift changes, transfers, or handoffs.
Nurse Brain Sheet Template
Nurse brain sheet example.
What are med surg report sheets?
A med surg sheet , also known as med surg brain sheet, is a specialized template used by nurses working in medical-surgical units or general hospital floors. These sheets are designed to capture and communicate essential information about patients admitted for various medical conditions or surgical procedures.
Unlike intensive care unit (ICU) brain sheets, which focus more on acute and critical care scenarios, med surg report sheets are tailored to address the unique needs of patients in general medical-surgical units. This includes tracking information on post-operative care, wound management, pain control, and any specific instructions for managing chronic conditions or post-discharge planning.
How to use our Nurse Brain Sheet Template
Using the Printable Nurse Brain Sheet Template is a straightforward process that enhances organization and communication in healthcare settings. Once you get your free downloads of our template, follow these simple steps to streamline your patient care:
Step 1: Patient identification
Start by filling out the patient's name, medical record number, date of birth, age, room number, and admission date in the top section. This ensures accurate patient identification.
Step 2: Medical information
Document the patient's admitting diagnosis, allergies, code status, diet order, and any relevant medical history or co-morbidities. This section provides a comprehensive overview of the patient's condition.
Step 3: Vital signs and assessments
Record the patient's vital signs, including temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation levels. Document any pertinent assessment findings, such as level of consciousness, pain scale, and intake/output.
Step 4: Treatment plan
In this section, list all the details of the patient's current medications, dosages, routes, and frequencies. Also, note any scheduled procedures, therapies, or special instructions related to the patient's treatment plan.
Step 5: Additional notes
Utilize the designated space to document any additional relevant information, such as lab values, diagnostic test results, skin/wound assessments, or specific nursing interventions required for the patient's care.
When should you use this Nurse Brain Sheet?
Our Nurse Brain Sheet Template is a versatile resource designed for various healthcare practitioners. It provides a structured approach to patient care in various clinical scenarios.
1. Regular patient shifts
Nurses handling regular shifts benefit from the template's comprehensive layout, ensuring a systematic tracking of vital signs, medications, and assessments. Its user-friendly format facilitates a quick overview of each patient's status, allowing for efficient decision-making and care planning.
2. Emergencies
In high-stress emergencies, the Nurse Brain Sheet Template becomes invaluable. Its organized structure aids in quickly grasping critical patient information, enhancing rapid response and timely interventions during crises.
3. Patient handover
The template is a reliable communication tool during shift changes or patient handovers. It enables a seamless transition of care between healthcare practitioners by consolidating essential patient data, ensuring continuity, and minimizing the risk of information gaps.
4. Multidisciplinary collaboration
In collaborative healthcare settings, such as intensive care units or surgical teams, the Nurse Brain Sheet Template fosters effective communication among diverse practitioners. Physicians, nurses, and allied health professionals can easily share and comprehend essential surgical or ICU patient information.
5. Long-term care planning
For patients requiring extended care or those managing chronic conditions, the template aids in developing and monitoring long-term care plans. Its adaptability accommodates evolving patient needs, providing a holistic view of their healthcare journey.
6. New admissions
When receiving new patients, whether in an acute care setting or clinic, the Nurse Brain Sheet Template guides practitioners in swiftly recording pertinent information. This ensures a comprehensive understanding of the patient's history and immediate needs, facilitating a smooth integration into the care environment.
7. Teaching and training
For educators and trainers, the template is an excellent teaching aid for nursing students or new healthcare practitioners. It instills the importance of systematic data collection and organization in delivering high-quality patient care.
The Nurse Brain Sheet Template is indispensable in numerous healthcare scenarios, promoting efficiency, collaboration, and optimal patient outcomes across diverse clinical settings. Its adaptability makes it a go-to tool for healthcare practitioners seeking to enhance their approach to patient care.
Explore our care plan template for added support in improving your practice and client results.
Commonly asked questions
Proper documentation by a nurse involves accurately and thoroughly recording patient information, including assessment findings, treatments, and progress. This includes documenting patient identification, vital signs, medications, treatments, and any changes in patient condition. Documentation should be clear, concise, legible, and adhere to the facility's or organization's specific guidelines and policies.
Nurses should avoid using certain words in documentation to ensure clarity and accuracy. These words include "normal," "stable," or "unstable," which can be subjective and open to interpretation. Additionally, words like "okay" or "fine" should be avoided, as they do not provide specific information about the patient's condition.
Common mistakes in nursing documentation include incomplete or inaccurate information, poor handwriting, and failure to include relevant details. Nurses may also fail to document patient information promptly, leading to delays in treatment or communication with other healthcare providers. Another common mistake is failing to sign and date documentation, which can lead to questions about the authenticity of the information.
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Nurse Brain: Creating Your Nursing Report Sheet
Organizing patient information and managing care during a shift can be a challenging task for nurses. Enter the nursing report sheet: an indispensable tool that streamlines patient care and helps nurses stay organized.
Organizing patient information and managing care during a shift can be a challenging task for nurses. Enter the nursing report sheet: an indispensable tool that streamlines patient care and helps nurses stay organized. In this blog post, we’ll uncover the anatomy of a nursing report sheet (sometimes called a "brain sheet" or "nurse brain"), explain how to create and customize your own, and delve into specialized report sheets for various nursing roles. By the end, you’ll have a better understanding of how these simple notes can enhance patient safety and improve overall nursing practice.
Key Takeaways
- Nursing report sheets provide an organized and systematic approach to facilitate patient progress tracking, collaboration between healthcare providers, and enhanced patient safety.
- Customizing a nursing report sheet can help streamline documentation processes, manage time, and improve patient care.
- Adhering to hospital protocols ensures that nursing report sheets are in line with HIPAA and the standards of the healthcare facility for optimal results.
Demystifying the Nursing Report Sheet
Nursing report sheets serve as vital tools for nurses, aiding in the effective organization and management of patient care. They help nurses stay organized during their shift by providing a structured format to record patient information, medical history, and tasks to be completed during the shift. Many report sheets use the SBAR format to organize information. This also makes it easy to give a concise report at shift change, or when contacting a doctor.
Nursing school students must learn how to craft their report sheet in a way that makes sense for them, while including all the pertinent information needed to effectively and safely complete their patient care tasks.
Employing a nursing report sheet offers benefits such as improved organization and efficiency in monitoring patient care.
Crafting the Ultimate Nurse Brain Sheet
Developing a nurse brain sheet, a resource for capturing and organizing crucial patient data, assists both nursing students and seasoned nurses in maintaining organization and focus on patient care. By developing your own brain sheet, you can ensure that all important information is at your fingertips, making it easier to track patient progress, communicate with other healthcare providers, and prioritize tasks during your shift.
For Student Nurses: Building a Brain Sheet from Scratch
For nursing students, constructing a brain sheet from scratch can be a valuable learning experience, as it helps reinforce patient safety and organization. Begin by keeping it simple and determining the sections you need, such as:
- Patient history
- Medications
- Vital signs
- Body systems status
Customize the layout, include relevant details, and regularly update and refine your brain sheet to suit your individual workflow and preferences. Of course, the best way to develop one is to see what works for other nurses and adapt it to your needs.
Some nurses like a horizontal layout, like the one shown here and some like it vertical, like the nursing.com sheet shown below. Some prefer a 4-square design like the title image. The choice depends on personal preference, but also, how the sheet is folded to fit in the nurse's scrub pocket! Some like to fold the sheet so only certain information shows, or so only one patient shows at a time.
Although common practice among nurses and nursing assistants, be careful about keeping it in your pocket. If you happen to be toting a pen, Saline flushes, IV port caps, and your phone, it can be easy to "lose your brain", meaning you not only lose your chart review info, but also your organization for the rest of your shift. Not to mention, it can also pose a risk of HIPAA violation if it should fall into the wrong hands.
Some nurses use a folding clipboard to keep better track of their brain and maintain the privacy of the information.
Time Management
One skill all nurses must learn to master is time management. Utilizing a report sheet can help you plan your shift. Some report sheets have a timeline on them to indicate when specific medications are due, and to plan specific treatments or tasks, such as wound care, catheter changes, bladder scans, or blood draws.
Having a good timeline on your report sheet will prevent you from reaching the end of your shift and suddenly realizing you did not complete a task. If you do, you must either stay late to complete it or pass the task on to the next shift, which should only be done sparingly, out of respect for your fellow nurses.
Tracking Lab Values
Nurses brain sheets use a universal diagram to organize lab values. It is often referred to as a "fishbone". There are a few different fishbone diagrams that include various sets of lab values from a CBC, BMP, ABG, etc. Most nurses will only need one or two of the main diagrams, such as CBC and BMP, but ICU nurses or cardiac nurses might need to use the ABG, Renal, or other diagrams.
Specialized Report Sheets for Diverse Nursing Roles
Report sheets designed for specific nursing roles, like cardiac care or ICU nursing, ensure comprehensive capture and effective organization of all pertinent information. These sheets are utilized by nurses to record relevant patient information and ensure continuity of care, making them an essential tool for various nursing specialties.
Cardiac Care Focus: The Heart of the Matter
Cardiac care-focused report sheets can dedicate spaces for cardiac information. This may include EKG readings, medication schedules, and post-procedure care details. By incorporating this vital information, cardiac nurses can provide more precise and comprehensive care to their patients through effective care plans, ensuring that the unique needs of those with heart conditions are addressed effectively.
The Critical Intensity of ICU Nurse Report Sheets
ICU nurse report sheets often contain more detailed information to help manage the critical needs of ICU patients. These report sheets include pertinent patient information such as:
- Demographics
- Medical history
- Current medications
- IV and titration settings
- Oxygenation status
- Fluid balance
- Laboratory results
- Ventilator settings (if applicable)
- Ongoing treatments or procedures
- Changes in the patient’s condition
- Nursing interventions and assessments
- Any noteworthy notes or concerns.
Free Downloads: A Treasure Trove of Nursing Report Sheet Templates
Numerous nursing report sheet templates are accessible for download from Nursing.com, enabling nurses to identify the ideal fit for their requirements. By exploring different templates and selecting one that best meets your requirements, you can ensure that your report sheet is tailored to your personal preferences and the specific needs of your patients.
There are report sheets available for purchase from Etsy, Amazon, and other sites, for a nominal fee. If you are a little bit computer savvy, and with the help of Canva or another design tool, you should be able to use examples as a guide to customize your own.
Nurse Report Sheet Notebook
by Fairy Nursing
Compliance with Hospital Protocols
Some hospitals have their own report sheets you can use during your shift, but if you have your own, you will always have exactly what you need, in the format that works for you. Be sure to follow HIPAA regulations with your brain sheet, keeping it in your possession, and never leaving it laying face-up where visitors or other patients can see. I would suggest trying out these folding clipboards as a way to keep track of your paper and protect sensitive information.
Also, don't take your work home with you! Always shred your brain or otherwise dispose of it per facility protocols at the end of your shift, before you leave.
Ensure that your report sheet complies with hospital protocols to maintain consistency and efficiency. By adhering to established policies and procedures, you can guarantee that your nursing report sheet is in line with the expectations and standards of your healthcare facility, ultimately providing top-quality patient care.
In conclusion, nursing report sheets are essential tools for organizing patient information and managing care during a shift. By understanding the anatomy of a report sheet, creating and customizing your own, and adapting to hospital policies and technology, you can enhance patient safety, improve communication, and streamline your nursing practice. So, take control of your nursing report sheet game and ensure the best possible care for your patients.
Frequently Asked Questions
What is the purpose of a nursing report sheet.
A nursing report sheet provide nurses with an organized system for tracking and managing patient care, allowing them to stay on top of their shift.
How can I customize my nursing report sheet for maximum efficiency?
Customize your nursing report sheet for maximum efficiency by considering the size, format, and content that best meets your needs and those of your patients.
What is the importance of accurate report sheets for patient safety?
Accurate report sheets are essential for patient safety, as they provide the relevant information required to ensure healthcare providers have the necessary details to deliver proper and safe care.
How often should nursing report sheets be reviewed and updated?
Nursing report sheets should be reviewed and updated regularly to ensure accuracy in patient care.
mold your lifestyle
Nursing · April 15, 2021
The BEST FREE Printable Nursing Report Sheet Brain (day shift & night shift)
Ok y’all – PD here. I FIRMLY believe that an organized nursing report sheet will set you up for success for a great shift. And even if you are having one crazy, hot mess busy shift (hopefully not too often), an organized detailed nursing report sheet (aka brain) will give you something physical you can refer back to & make you feel like you have everything under control.
I attached my ABSOLUTE FAVORITE Nursing Brain Report sheet that I have used for YEARS. Unfortunately, my current workplace has a dedicated nursing report sheet brain we need to abide by, BUT if you don’t have a required report sheet to use, DOWNLOAD THE FREE PDFS BELOW . I’ve included both day shift (0700-1930) and night shift (1900-0730) report sheets.
The reason why I LOVE this particular brain (report sheet) is because of how minimal but detailed it is. You can easily find the pertinent information you need at the top where it’s most important, and then each hour of your shift boxed below it.
Disclaimer: I do work on an acute care floor, so for my ICU friends or another specialty, this might not be the best fit for you. But hey, it’s FREE so if you like it download it!
April 16, 2021 at 1:25 am
this brings back memories! such a good one PD!
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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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NurseMind's Brain Museum
Every nurse knows what we mean by . You're not a nurse? It's explained . Remarkable ingenuity goes into creating nursing brains. In them, we capture an important aspect of our work: the things we want to be sure not to forget. We use a variety of tools to create these brains: Excel, Word, text editors -- whatever application programs we know best. For consistency, all are presented here in PDF format. Collecting brains is more than just an amusing exercise. It reveals much about the thought processes underlying the complex profession of nursing. From the choices we make about the reminders we find helpful, you can see our perceptions of the cognitive burdens of our work. Studying these brains reveals many of our challenges. When we find it necessary to write things down, These insights gave us the design concepts used in our , the first in a growing family from THANK YOU to all the generous and brilliant nurses who shared their brains with us! |
COMMENTS
Nursing Brainsheet Database by NRSNG.com
The Ultimate Nursing Report Sheet Guide - Free ...
What is a Nursing Report / Brain Sheet? Free Templates!
Brain Sheets - Straight A Nursing ... Brain Sheets
What is a Nurse's Brain sheet and how do you use it?
Ultimate Nursing Report Sheet Database & Free ...
With this Free PDF Download from Carepatron, you'll have a ready-to-use Nursing Brain Sheet template that you can customize to suit your unique needs. As you familiarize yourself with this guide, you'll understand why a well-designed Nursing Brain Sheet is a game-changer for healthcare professionals. Stay tuned, and get ready to transform your ...
A nurse brain sheet, also known as a nursing report sheet or a patient report sheet, is a comprehensive document used by healthcare professionals, primarily nurses, to record and communicate essential information about a patient's condition, treatment plan, and ongoing care. These sheets are a centralized location for documenting vital patient ...
Nurse Brain: Creating Your Nursing Report Sheet
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 response was AMAZING (to say the least). We received over 100 report sheet templates from nurses working ...
I attached my ABSOLUTE FAVORITE Nursing Brain Report sheet that I have used for YEARS. Unfortunately, my current workplace has a dedicated nursing report sheet brain we need to abide by, BUT if you don't have a required report sheet to use, DOWNLOAD THE FREE PDFS BELOW. I've included both day shift (0700-1930) and night shift (1900-0730 ...
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. ... Nursing OnPoint is a better way to learn, share knowledge, and socialize ...
NurseMind's Brain Museum
Custom Nursing Report Sheet (Version 1) FREE DOWNLOAD. The front page consists on basic patient info, report from previous shift, lines, labs, neuro report, blood gases (if needed), etc. The back page is meant to be separated into four quadrants (we preferred to fold it, but you could mark it with your pen).
This customizable and downloadable free nursing report sheet will help keep you organized and efficient at work. ... Click here to be directed to a youtube video for directions on how to customize your nursing brain sheet on canva. Download the Customizable Canva nurse report sheet here. Download Me.
Brain Sheets Decoded: Episode 108. In episode 7 I talked about how to give an excellent end-of-shift report. In this episode, we're taking a deep dive into how nurses use "brain sheets" to ensure that report is thorough and efficient. We'll go through all the components of an effective brain sheet so you can feel confident in the ...
The Perfect Med-Surg Nurse Brain Sheet
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.
3. Reusable Nursing Brain Sheet. This brain sheet is awesome for nurses who don't want to hassle with printing a new one every time they work. It's reusable — just wipe off your notes and jot down fresh ones next time you're on shift. It's perfect for cardiology, medical-surgical, and progressive care units.
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.
We asked you for your best brain sheets, and you delivered! Here are the best of the best. 1) New Shift Report 2) Hour, Day and Night Rotation 3) ICU with charting reminders 4) Binder Insert with Dividers 5) Binder Insert with MARS 6) Telemetry Unit SBAR 7) Shift Hours 8) Half Size 9) MedSurg Notecards 10) Three Patient Moreover, considering today's conditions, students can get a degree ...
Streamline your nursing processes with our comprehensive Nursing Brain Sheets guide. Download our free PDF template and enhance your patient care today:www.c...
Free Nursing Report Sheets