Nurse Shift Report Sheet

• Patient Name

• Patient Room

• Conducted on

  Date

• Prepared by

General Information

• Date of Birth

  Date

• Sex

  Male

  Female

• Admitted

  Date

Patient Report

• Diagnosis

• Procedure

• Does the patient has allergies?

  Yes

  No

• Please enter details

• Patient medical history

• Code status

Patient Monitoring - Vital Signs

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Patient Check

• Time Check

  Date

• Blood Pressure

• Heart Rate

Temperature

• Oxygen Saturation

• Oxygen

• Respiratory Rate

• Pain

• Blood Sugars

• Are there dispensed medications?

  Yes

  No

  N/A

• Time of Med Pass

  Date

Intake

• Breakfast

• Lunch

• Supper

• Other

Output

• Foley

  ✔

  ✖

  N/A

• BM

  ✔

  ✖

  N/A

• Emesis

  Yes

  No

  N/A

• Drains

  ✔

  ✖

  N/A

• Tubes

  ✔

  ✖

  N/A

• Ostomy Bag

  ✔

  ✖

  N/A

Labs and Needed Procedures

• Labs

• Needed Labs

• Future Procedures

Other

• Discharge Plan

• Variance to Discharge Plan: Barrier

• Resolution

• Consults

Completion

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Nurse

• Full Name and Signature of Nurse Attendee

  Sign