The Ultimate Nursing Report Sheet Guide - Free Downloads!

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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.

nurse report sheet for 6 patients

1. Full-Size SBAR Nurse Report Sheet

nurse report sheet for 6 patients

  • 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

nurse report sheet for 6 patients

  • Brain format

3. ICU Nurse Report Sheet

nurse report sheet for 6 patients

  • Great for ICU

4. Mini SBAR Nursing Report Sheet

nurse report sheet for 6 patients

  • 3 patients per sheet
  • Quick report taking with circling options
  • Great for med surg and tele units

5. 4 Patient Nurse Report Sheet

nurse report sheet for 6 patients

  • 4 patients per sheet

6. Brain Nursing Report Sheet

nurse report sheet for 6 patients

7. 2 Patient Landscape Nurse Report Sheet

nurse report sheet for 6 patients

  • 2 patients per sheet

8. 3 Patient SBAR Nurse Report Sheet

nurse report sheet for 6 patients

9. Full-size Nurse Report Sheet Template

nurse report sheet for 6 patients

10. History and Physical Template

nurse report sheet for 6 patients

  • H&P format
  • Great for nurse practitioners and NP students

Free Downloads!

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I started collecting brains and building this museum in 2008. In recent years, others have started doing this, too. For example, a guy who built a web site named www.nrsng.com collected these .

Copyright 2008, 2023 © Dan Keller RN MS

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Ultimate Nursing Report Sheet Database & Free Downloads

nurse report sheet for 6 patients

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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.

HANDOFF and REPORT SHEET

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.

nursing student clinical sheet

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.

Patient Simple Tele Sheet

  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.

med surg clinical sheet

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.

assessment sheet for nurses

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.

nursing organizer

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!

Postpartum report

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.

simple nursing

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!

MOM-BABY Brain Sheet

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:

Detailed ICU Nurse Report Sheet

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).

Charge Nurse Report Sheet for Nursing

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!

5 PATIENT VERTICAL BRAIN SHEET

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.

ICU REPORT sheet

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.

BOX NURSING REPORT SHEET

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.

HOURLY BRAIN SHEET FOR NURSES

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.

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.

emergency room report

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.

nursing rounds template

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.

NEURO ICU brainsheet template

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!

WHITESPACE NURSING ASSESSMENT SHEET

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.org

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

What is a Nursing Brain Sheet?

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

nurse report sheet for 6 patients

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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Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. Join the nursing revolution.

Nursing Report Sheet Templates | Free Report Sheets for Nurses

Nursing report sheets are premade templates of paper used by nurses to help them keep track of their patients. A nursing report sheet is started at the beginning of the nurses shift while she/he is getting report from the leaving nurse who is giving them nursing report.  This nursing report sheet should not be confused with the SBAR tool which is a tool used as a guide for giving nursing report.

Why Do Nurses Use Nursing Report Sheets?

Nurse report sheets are very handy because they contain tidbits of vital information concerning your patient’s diagnosis, history, allergies, attending doctor,consults, things that need to be done on your shift, medication times, vital signs, lab results etc. The report sheet has other usage as well. Other usages of the nursing report sheet include but are not limited to:

  • Keeping track of telephone orders received from doctors
  • Critical Lab values called to you from lab
  • Helps you keep track of intake and output
  • Helps you keep track of blood sugars and insulin coverage
  • Nursing notes to remind yourself of things you need to do for the patient or chart on
  • Notes to yourself on things you want to remind the next shift

Most nurses who use report sheets consider their report sheet to be their “brain,” and panic when they misplace them. Nurses who use them tend to keep them folded in their scrub pocket or on their clip board for easy access.

Always make sure to get a good report on your patients before starting a new shift. Learn more about questions to ask when getting report .

Video on How to Give Nursing Shift Report

Benefits of a Nursing Report Sheet

  • Fast access to patient information. If you are asked by a doctor what a particular patient’s INR was you could simply look at your report sheet to find out. You won’t have fumble around and try to remember which patient he/she was talking about.
  • Helps you keep track of things you need to get done before your shift is over.
  • Helps you differate between each patient. When you have a 6 to 7 patient load, patient diagnosis and histories can run together and you may get them confused.
  • Helps you keep your charting more accurate. If you write down on your report sheet things you need to remember to chart, your charting will be more accurate and easier to do. Again with 6 to 7 patients things tend to run together.

Nursing Report Sheets (Templates)

Nursing Report Sheets, Nurse Report Sheet

Remember to always shred your report sheet at the end of your shift. Never take your report sheet home with you!

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Anonymous says

May 24, 2015 at 3:26 am

Ur just too good n doing a praiseworthy job.thank u so much.god bless

S.L. Page says

May 24, 2015 at 4:24 am

I just wanted to thank you personally for this comment. Comments like these are very encouraging and motivating. Thank you again for taking the time to comment these kind words.

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FREE Nursing Report Sheets & How to Make One

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Nursing report is an important part of a shift. Having a good nursing report sheet can help ease the transition for new nurses and even keep veteran nursing on track. The best part, these are all free nursing report sheets!

The nursing sheets provided, I designed throughout nursing school. They were developed into what they are today as I started working in a neurological ICU and surgical ICU. These are perfect critical care nursing report sheets and are perfect for anyone who needs pediatric, cardiac, med-surg, telemetry, or postpartum nursing report sheets .

What is a Nursing Report Sheet?

Nursing report sheets are used by nurses to obtain shift report. Shift report happens between nurses when they switch nurses for the shift. Shift report includes information about each patient. It is important to include vital potent information in report while being quick.

The report sheet should include the patient’s name, reason for admission, any co-morbidities and other pertinent information. Pertinent information will depend on what floor you work on, but typically includes the medications for the day, code status, nutrition status, labs and vital sign trends.

It can be nice to find free nursing report sheets, but it is important to remember, you should make it your own!

Buy Now

Why Do Nurses Use Report Sheets?

Most nurses will use nursing report sheets to write down information for each patient. It is difficult to recall everything so writing it down helps a lot. There are some great nursing clipboards that can help you organize your papers for the day.

As I mentioned before, nurses will write down information used for the day. However, some nurses might even plan out their day. I typically use my sheets to create a plan for medications and charting expectations for the shift. It is important to mark when you need to chart certain things and obviously pass medications.

Nursing Report Sheet ICU

This is my favorite custom critical care nursing report sheet. I made this report sheet when I was precepting in the neuro ICU. I learned a lot during my time there and really was able to create a custom report sheet. Creating something custom allowed me to perfect my nursing report skills and really helped me as a new nurse.

I wanted to allow everyone to customize these free nursing report sheets to adapt them to their own floor.

nurse report sheet for 6 patients

Nursing Report Sheet (Version 1)

Send download link to:

icu-report-sheet

The front page consists on basic patient info, report from previous shift, lines, labs, neuro report, blood gases (if needed), etc.

nurse report sheet for 6 patients

The back page is meant to be separated into four quadrants (we preferred to fold it, but you could mark it with your pen). And we proceeded to use the top two quadrants for medications (including time and info) and the bottom two for the shift’s schedule (time and info) and extra info to give to the next shift report.

Telemetry Nursing Report Sheet

This is a tele nurse report sheet, but it is also great as a med-surg nursing report sheet. This telemetry nursing report sheet is a template you should customize to fit your needs.

In addition, this sample nursing report sheet is used as a template for nursing students or clinical groups. It is great to learn with because it lists all of the important portions of a nursing report in order.

telemetry-report-sheet

Nursing Report Sheet (2nd Version)

Med-surg nursing report sheet (medical-surgical floors).

Here we have a few med-surg nursing brain sheets or report sheets. These are designed for nurses who have more than 1-2 patients.

With my time in the ICU, I learned to manage 2 patients fairly well. However, some med-surg nurses manage upwards of 7-8 patients per shift ( which I could never understand ), but that means that need to stay organized.

Any seasoned nurses know that organization is 99% of the job. But, for the new nurses, keeping yourself organized can be challenging. So, hopefully these nursing report sheets (nurse brain sheets) can help the med-surg nurses. But, even other nurses can customize them to their liking!

3 Patient Nurse Report Sheet

nurse report sheet for 6 patients

4 Patient Simple Report Sheet

nurse report sheet for 6 patients

How to Make Your Own Nursing Report Sheet

Creating your own nursing report sheet is actually easier than it might sound. Typically using Microsoft Word allows you to cater to your own needs.

nurse report sheet for 6 patients

Start by downloading one of our free templates. Once you have one downloaded, you need to open them in Microsoft Word or another comparable word processing program. Once in, you can edit any of the boxes with text. Just highlight the text and change it!

For example, to change what lab values are their or perhaps which assessments, just highlight the text and type! Once you’re finished, just print it and you’re set!

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Straight A Nursing

A report sheet (also called a "brain sheet") is simply a reference used by nurses so they can keep track of important information about each patient. This sheet is often filled out with key information during change-of-shift report and then updated as things change (and they always do!). The brain sheet is then used at the end of shift to give report to the oncoming nurse. Having a good brain sheet is key for patient safety and effective communication.

✏️ Click to get report sheets for ICU, Med Surg and Telemetry.

Need more info on how use a brain sheet for report?

Here's what a Med-Surg brain sheet looks like at the beginning and end of shift. I'll talk you through each component in the video below (scroll down!).👇

Sample report sheet

How to use a brain sheet tutorial video

In this quick video, I'm talking you through how to use a report or "brain" sheet at the beginning and end of your shift. Watch to learn the components of a report sheet, how to use each section, and how to utilize this document to give end-of-shift-report.

✏️ Click here to download FREE report sheets for ICU, Med Surg and Telemetry.

37 Comments

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Nurse Mo, I think your website is the best! I will be starting my 4th semester nursing thru an ADN program. I’m typically an A and B student, but I missed the mark by 2 points for 3rd semester and received a C. Hopefully 4th won’t totally bog me down! However, I usually do pretty good with clinical, but this semester we will be on our own, so looking forward to all the goodies you have provided. Thank you for unselfishly thinking of us when you have a career and family to think about.

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Good luck with 4th semester…you’ll do great! This is when it all comes together…you’ll be surprised how much you know (and also surprised at how much there is still to learn). Stay focused on the patient and TAKE CARE of yourself and all will be well 🙂

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Do you have anything related to a brain for a med -surg floor ? I love the flow of yours and all the details, I am just not an ICU nurse.

I’ll have to look Becca…I think I have a link to a tele one…that should work for M/S.

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If you are still looking, check out the one I have created for med surg https://nurseologyblog.wordpress.com/2016/02/26/shift-at-a-glance-checklist/

Hope that helps!

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Would you happen to have a “brain sheet” that is more geared toward the respiratory system? I’m a Respiratory Therapy/Care student. If not, could you point/lead me in the direction where I may find one?

Good question! I don’t have one and I honestly wouldn’t know how to go about making one! The best thing might be to ask the RTs at the facility where you do your clinical rotations. I know I’ve seen the RTs at my hospital use them, but I never took a close look. Sorry! And best of luck with RT school…such a cool job!

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I love your ICU brain sheets? Do you happen to have one I could edit? If not, I understand! Thanks! 🙂

I don’t…the files are huge InDesign files. Thanks for loving them, though!

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Hi , do you have any notes biliary and pancreas disorders ? Can you post some please ? Thanks.

Ina…I will look! Maybe I’ll create a case study…been wanting to do that for a long time!

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Is their a way to print these? I would love to use these for my handoff 🙂

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Hi, is there anyway you can make a labor and delivery one? Im a new l&d nurse and still trying to come up with a more organized way to receive and give report

Hi Celeste! I would have to get help from my L&D friends as I have NO IDEA what sorts of things you need on a brain sheet. If anyone wants to share their insight, I’d be happy to!

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Love it. Doesnt quite work for ED. Reiterates the difference between ED and ICU brains to me though. WELL DONE!!

Oh yeah…ED IS TOTALLY DIFFERENT! I’d love to create a brain sheet for the ED, but what I was thinking was make it 4 to a page so you can essentially cut them out into small little “mini brains” to write down just the key info….then toss when that pt leaves. How many patients do you think you see in a day? I imagine it can be a lot!

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This is one of the best peripheral brains I have seen. I recently transferred from ED where I was able to keep all that chaos bottled inside my head. The ICU is a completely different animal and I am afraid my poor brain will overload with trying to remember all the labs and vent settings, gtts, etc. Love this brain!

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Do you have a link to open these on a word document? I like typing and it would be great to have this there!

Sorry…I don’t use Word 🙁 All my items are created using design programs, but it’s so easy to make your own! I highly encourage people to make their own brain sheets since they will work the way YOUR brain works 🙂

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Hey I was wondering if you have a word document copy of this. I would really like to type up my report because my handwriting looks like I am having a seizure during report lol

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I would love a copy of the run shift, I work the tele floor and haven’t found one that really suits my needs yet.

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Hello! do you have a brain sheet or anything to keep me organized during my shift, I am a new nurse working in the NICU. Thank you!

I don’t have one specific to the NICU, but you could start with the one-patient sheet and then adjust it for your needs. I know there are specific NICU things that don’t apply to adults…let me ask some NICU nurses and see what they suggest 🙂

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Nurse Mo, could you please make a “key” for your medsurg brain sheet or show an example of a completed sheet?

Hi Alison…that’s a great idea! In the meantime, please check out my latest podcast episode where I talk you through this sheet step-by-step! https://straightanursingstudent.com/episode108/

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Do you have Icu brain for PM shift?

This is the only one I have…I used it for days and NOCs. Are you referring to the run sheet with the time slots on it? It’s possible I have one…send me an email 🙂

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Nurse Mo! I’ve been a listener for 2 semesters now and I love your content. It’s detailed and to the point. I get to listen before my lectures so I have an idea of how the content will flow. It’s been helping me through each semester. I’m currently in my last semester doing A LOT of critical care content. My plan is to be somewhere in the Pediatrics, specifically Cardiac. Thanks for being my cheerleader and virtual supporter!

Hi Diana…thanks for the thoughtful feedback! So glad the podcast is helping you!

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Hi Nurse Mo! I’m heading into a surgical rotation and would love to use the brain sheet particular to this rotation…when I go to the Etsy link it tells me that this item is no longer available :(. Could you point me in the correct direction for one? Love, love your podcasts!

Hi Monica – the closest one I have currently is the Telemetry Brain – I think you could use that one just fine! And, since many patients on a surgical unit are on telemetry monitoring, you’ll be covered 🙂 Good luck in your surgical rotation!

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hello I am a nurse from a non English country, Is the Giving End-of-Shift Report: Episode 7 podcast transcript available?

Not a transcript, but this may help! https://straightanursingstudent.com/be-an-end-of-shift-report-rockstar/

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Hi there! I found you through your PACU episode on your podcast! I’m an ICU RN transitioning to PACU. I don’t normally use a template for a brain but with the high pt turnover in the PACU and the frequent reports with anesthesia and OR (and unfamiliar anesthesia/reversal meds), I’m thinking I might need one at the beginning. Do you have a PACU brain or link? Thanks for your episode! Really enjoyed it.

Hi Sophia…welcome to The Good Life 🙂 You’ll LOVE PACU! It’s so great for so many reasons! When I first started I did make a little brain sheet but as I got more experience I realized what I actually needed to write down for my patients and I just do that on the fly.

When we get our patient assignments, they come on a slip of paper that’s about 8.5 inches wide and 4 inches tall. I turn that over and place it vertically…I then create three equal sections.

In the top section I write any PMH that’s relevant to me in the PACU. If they take any meds I need to know about I jot those down here as well. This is also where I include any allergies.

The middle section is for surgery…I write down what meds ANES gave, how long the surgery was (patients often ask, so I like to have it handy), any drains that were added, dressings, blood products, EBL, IVF intake and output (if they had a Foley).

The bottom section is for PACU. On the right side I write my standard to-do list “EKG strip, orders (to remember to get orders if I don’t have them yet), IV Fluids, Care plan, Education, Out note (upon transer). I’ll also add anything specific for that patient like a glucose POC, 12-lead, arm sling, abd binder, x-ray, labs, neuro checks, etc…

And the rest of that bottom section is where I jot down any notes that I’ll need to convey in report.

Easy peasy! I hope that helps!

Mother Nurse Love

5 Best Nursing Report Sheets & Notebooks

by Sarah Jividen | Apr 21, 2023 | Nurse Gifts , Nurse Life , Nurse Scrubs & Accessories

Nurse organization is essential for patient safety.

*This post contains affiliate links/Updated from original post on 1/21 .

During my first clinical rotations as a nursing student, I was so in awe of how nurses were able to remember so much information.  It is hard to explain to a non-medical person how much data nurses have to remember unless you see it or experience it firsthand.

I saw my first nursing brain sheet during my first pediatric ICU rotation.  The nurse I was working with was very professional when working with her patients and their families.  She seemed very busy but not overly stressed, which was impressive considering the high acuity and age of her patient population.

That was also the first time a nurse explained how to keep a patient’s medical information – using a nurse’s brain sheet – organized in a way that made sense.

These days, hospitals are mostly paperless and use interactive computer systems – such as EPIC – to chart patient information.  Computer charting software is essential so that patient’s medical information is in one place. Also, there is less paperwork to get lost, there is no messy handwriting to decipher, and the patient’s information can be shared among all ancillary staff:  doctors, physical therapists, respiratory therapists, case managers, etcetera.

But even with substantial technological advances in paperless charting, it is still beneficial for nurses to keep essential information at their fingertips.  This is where a nursing report sheet comes to play.

nurse report sheet for 6 patients

How We Choose The Best Nursing Report Sheets

Choosing the best nursing report sheets can be overwhelming, with so many options available. In choosing these report sheets, we considered several factors, such as whether they were written by nurses, their helpfulness, and online reviews.

We’ve read through many user reviews and star ratings to develop a list that makes your life easier and provides information to help you make a good decision. Choosing the perfect nursing report sheets and notebooks requires some extra considerations to ensure it meets the unique needs of a nurse.

Here Are The Top 5 Best Nursing Report Sheets:

#1.  ez handoff – nursing report sheets.

nurse report sheet for 6 patients

CHECK PRICE HERE

Why We Love This

  • The book contains 80 customizable templates for patient information
  • The templates follow the SBAR (Situation, Background, Assessment, Recommendation) format
  • The templates include various sections such as Head to Toe Assessment, Vitals, Past Medical History, Labs, and other important clinical information
  • It is spiral-bound and has a front and back cover for durability and HIPAA compliance.
  • Each patient has one double-sided template that can be filled in and edited as needed.

Additional Info

  • The book measures 6″ x 6″ and can fit in most scrub pockets

#2. Nurse Report Sheet Notebook Pocket Notebook for Nurses

nurse report sheet for 6 patients

  • The package includes 2 nursing report notebooks, each containing 80 pages, providing enough quantity for daily use and replacements.
  • The shell of the nursing report sheet is solid, and the report sheet is made of quality cardboard, which is thicker than conventional papers, making it durable and not easy to break or tear.
  • The inner pages of the notebook include a variety of comprehensive templates, such as head-to-toe assessments, vital signs, past medical history, labs, and other relevant clinical information, allowing for a fully documented and optimal treatment modality.
  • The cover of the notebook features eye-catching and meaningful designs, such as an echometer, hospital bed, and text “Report Made Simple,” making it beautiful and giving you a good mood to work.
  • The notebook is convenient to carry, measuring approximately 15.2 x 14.5 cm/ 5.98 x 5.71 inches, making it a proper size to put in your pocket, gown, or bag, saving space for you.

#3. Nursing Brain Sheet Multiple Patient Notebook

nurse report sheet for 6 patients

  • The package includes two nursing report notebooks, each containing 80 pages, providing enough quantity for daily use and replacements.
  • The shell of the nursing report sheet is solid, and the report sheet is made of quality cardboard, which is thicker than conventional paper, making it durable and not easy to break or tear.
  • The notebook is convenient to carry, measuring approximately 15.2 x 14.5 cm/ 5.98 x 5.71 inches, making it a proper size to put in your pocket, gown, or bag.

#4. Nurse Report Sheet Notebook

nurse report sheet for 6 patients

  • Keep track of your patient’s medical history, vital signs, and lab results with this notebook.
  • The notebook is designed to help you stay organized and provide the best possible care for your patients.
  • This beautifully designed notebook makes a great gift for ICU nurses, nursing students, recent graduates, RNs, LPNs, public health nurses, hospice workers, and home health care professionals.
  • The notebook features background information and one patient per sheet, with frequently-needed info strategically placed at the top of the sheet.
  • The notebook also includes a brain sheet to help you stay organized and a head-to-toe assessment section.
  • The notebook is perfectly sized at 8.5″ x 11″ (21.59 x 27.94 cm) for portability and practicality.
  • It contains 140 pages, providing ample space for notes and patient information.

#5.  Nurse Brain Sheet

nurse report sheet for 6 patients

  • You can obtain an endless supply of Brain Sheets by copying them at work before each shift.
  • The provided sheet can fit up to four patients if copied front and back.
  • The common report sections are already printed on paper, saving you time when taking and writing down end-of-shift notes.
  • This brain sheet was created by experienced nurses and is designed to help you stay organized. It’s suitable not only for new graduates but for all floor nurses.
  • You’ll receive three high-quality Master Sheets that will provide you with a clear copy every time.

What is a Nursing Report Sheet?

Nursing report sheets keep nurses organized and patients safe.

A nurse report sheet, also referred to as a nursing brain sheet, is a piece of paper that contains organized information on your patients.   The sheets will look different depending on what specialty you work in at the hospital.

Some of the information on a nursing brain sheet includes history, diagnosis, medications, allergies, DNR status, lab values, NPO status, family phone numbers, and any other patient care notes you need to remember during your shift.

Many nurses get used to using a particular nursing report sheet early in their careers – and then they keep using it throughout their entire careers, no matter what specialty they move into. Although different hospital specialties focus on specific patient information, you may want to use one that is specific to your specific patient population.

For example, a neuro nurse who cares primarily for patients with traumatic brain injuries will have a different brain sheet than a cardiac ICU nurse. Each patient population focuses on different organs, lab values, medications, and treatments, and usually has different benchmarks that they strive for during each shift.

Nursing Report Sheet Frequently Asked Questions

What should be included in a nursing report sheet.

A nursing report sheet typically includes patient information such as their name, room number, and diagnosis. It also includes the patient’s vital signs, medications, and any specific care instructions.

How can I make my own nurse report sheet?

To make your own nursing report sheet, start by determining the key information you need to include such as patient demographics, care instructions, and vital signs. Then, create a template that is easy to use and follow.

How do you write a nursing care report?

When writing a nursing care report, start by reviewing the patient’s medical record and taking note of any changes since your last shift. Include vital signs, medications, and any interventions or care provided. Be sure to document any important information related to the patient’s condition and progress.

Why are nursing report sheets important?

Nursing report sheets are important because they help to ensure that critical patient information is communicated accurately and efficiently between shifts. They also help to keep nurses organized and ensure that all necessary tasks are completed.

What is a brain sheet in nursing?

A brain sheet in nursing is a document that helps nurses keep track of important patient information, such as vital signs, medications, and care instructions. It is typically a template that is customized to meet the needs of the nurse and the patient.

What are nurses’ notes called?

Nurse’s notes are often referred to as progress notes or nursing documentation. These notes are a record of the care provided to the patient and may include vital signs, medication administration, and any changes in the patient’s condition.

What is a nursing assessment sheet ?

A nursing assessment sheet is a document used to record a patient’s medical history, vital signs, and any other relevant information related to their health status. It is typically completed by the nurse at the beginning of their shift and helps to guide their care plan for the patient.

nurse report sheet for 6 patients

What are the best nursing sheets and notebooks?

Here are some final tips to consider when purchasing a nursing report sheet:

Look for a report sheet that is customizable to meet your specific needs and the needs of your patients.

Consider the size and format of the report sheet. A compact, portable option may be best for nurses on the go.

Check for the durability and quality of the paper. A high-quality report sheet will hold up well throughout your shift and provide a clear, readable copy.

Look for report sheets that experienced nurses or healthcare professionals design to ensure they include all the necessary information and are user-friendly.

Consider the cost and the number of sheets you will receive. It may be more cost-effective to purchase a larger quantity of sheets at once.

Finally, be sure to test out the report sheet before committing to a large purchase. This will give you a chance to see if it works well for you and meets your needs.

Nursing Report Sheet Best Advice

So what are the best nursing report sheets? The answer may vary from person to person, but we’ve tried to provide a variety of the best options for you to choose from based on reading thousands of reviews.

All you have to do is just tap the button for more information. Thanks for stopping by!

Additional Recommended Reading:  

  • 9 Benefits Of Being A Per Diem Nurse (PRN Nurse)
  • Ultimate Top 30 Nurse Supplies & Essentials: The Complete List
  • 14 Best NEW Nurse Bloggers & Influencers In 2020
  • The Best Backpacks for Nurses
  • What to Wear Under Scrubs

Follow Us On Instagram

Mothernurselove.

Healthcare Journalist & Content Marketing Writer @ Health Writing Solutions portfolio @ www.sarahjividen.com

Sarah, RN, BSN

Sarah Jividen Media LLC © 2023

All rights reserved, read the blog, privacy policy, disclosures, terms and conditions.

Nursing Report Sheets

Download a free Nursing Report Sheet template and PDF example. Understand the key components of nursing reports and how to best use them in your practice to get the most out of patient information.

Ericka Pingol

What is a Nursing Report Sheet?

Nursing reports are essential for providing quality healthcare. They serve as a patient care record and allow nurses to share their findings with the rest of the medical team. They can also help maintain high standards of care and ensure patients receive the best possible treatment.

Nursing reports provide an opportunity to review patient history, compare treatments, and evaluate outcomes. They provide a framework for nurses to analyze patient responses to treatments and medications, enabling them to make informed decisions about the care of their patients. Reports also help nurses identify potential safety issues or areas needing improvement.

Nurses use a to document patient information. It typically includes details such as the patient's name, medical history, medications, and treatments. The form tracks changes in a patient's condition over time and records progress notes and other details related to the patient's care.

Printable Nursing Report Sheet

Download this Nursing Report Sheet to maintain accurate documentation.

How does it work?

Our printable Nursing Report Sheet is divided into various sections to make filling it out easier. The sections include patient information, medications, vital signs, and assessments. Here's how to get started with this free template:

Step One: Obtain a copy

Download the free Nursing Report Sheet template using the link on this page or from the Carepatron app. You can also find it in our extensive resources library.

Step Two: Enter patient information

Begin by entering the patient's name, age, and other relevant personal information. Then, enter the patient's medical history, including any chronic conditions or medications they take.

Step Three: Record relevant details

Use the template's sections to record the patient's vital signs, lab results, interventions, and other pertinent information. List any treatments or medications the patient takes and their response to them.

Step Four: Save your report

Once you've completed the Nursing Report Sheet, save it in a secure place. Doing this will make referring to the patient's information easy.

Nursing Report Sheet Example (sample)

We have created a Nursing Report Sheet PDF example to illustrate how our free template works. This sample is written by a hypothetical nurse making a report for an older patient. You can view the sample here or download the PDF version as a reference.

Download the free Nursing Report Sheet Example (sample):

Nursing Report Sheet Example (sample)

When would you use this Template?

You can use the Nursing Report Sheet template anytime you need to provide a patient assessment and care plan. This includes admissions, follow-up visits, post-operative assessments, and other scenarios. This form is also useful to:

Monitor vital signs

Using a Nursing Report Sheet, you can easily track and record a patient's vital signs , such as heart rate, blood pressure, respiration, temperature, etc. This information can help you create a comprehensive picture of the patient's health condition.

Document interventions

When assessing patients, it's essential to document any interventions or treatments that have been performed. A Nursing Report Sheet can help you keep track of all the steps taken to ensure a patient's safety and well-being.

Provide a comprehensive overview for other medical professionals

This template can provide a comprehensive overview for other medical professionals who may consult on the patient's care. This can help ensure that the patient receives the best possible care.

Keep a secure record of patient information

The Nursing Report Sheet is an easy way to store patient information in a secure, confidential manner. It can help you monitor important information and provide quick access to the data if needed.

Benefits of free Nursing Report Sheet

This free Nursing Report Sheet is a fantastic resource for nurses and other care providers. Here are some benefits of the template:

It saves time

The Nursing Report Sheet template is designed to be completed quickly and accurately. This helps you save time that would otherwise be spent on paperwork - meaning you can add more value when it come to assessing patients. It's a win-win, especially in nursing when schedules can be beyond hectic.

It's customizable

Our free template provides various sections to make your filling-in information easier. However, you can customize the sections to suit your individual needs. Every nurse and hospital organization has their own way of noting down patient details, and we recognize this. It's super easy to cater them to meet your needs, however, you may like.

It's fully digital

The Nursing Report Sheet template is fully digital, meaning you can fill it out electronically, print it off or share it with other medical professionals. We know the world is becoming more and more digital to save time and elevate efficiency, and so we've got you covered. This template makes gathering and managing patient information more efficient and secure.

It's extremely flexible

It can easily be adapted for different healthcare settings and patient needs. This makes it an excellent tool for any healthcare provider, regardless of the type of nursing you're trained in.

Nurse software positive feedback

Commonly asked questions

Nursing Report Sheets are used by nurses, medical professionals, and other healthcare providers to track patient data. They can be a critical tool for ensuring patient information is accurately managed.

You can use Nursing Report Sheets at any time to track patient data. It can be used to log patient information, record symptoms or treatments, and track progress over time.

A Nursing Report Sheet can help healthcare professionals track patient data more effectively. It makes the process easier and more organized, allowing for better accuracy and faster record-keeping.

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Nursepective

Empowerment in Nursing and Beyond

A Budding Nurses’ Guide to Nursing Report Sheets: With Free Customizable Template

February 27, 2022 · In: Nursing School

Nursing Report Sheets

A nurse's life is hectic. It can be difficult to keep track of everything that goes on at work, especially when you are juggling a million things all at one time. That's why many nurses turn to nurse report sheets to help keep their work lives organized and efficient!

As a nurse straight out of nursing school, you probably are wondering what you can do to prepare yourself for that new job. No? Then you maybe have started work already and have had instances where you felt horrible after shift report.

It might be because the oncoming nurse had you feeling horrible for not having all your patient information ready during shift change, or they called you out because you forgot a few important details of the patient's care. I know how that feels, I have been there.

Don't worry! I have an excellent solution to this problem. I am glad you are finding ways to improve, which is why you are on my blog now. I will ensure you have all you need to give an accurate and in-depth report by the end of this read.

The answer to your problem is a customized nurse report sheet, a nursing report sheet, a nurse brain sheet, a brain sheet, or however you like to call it.

I promised a free customizable report sheet. I will attach it below. I will include a PDF version for those who love the way it looks and can work with it and a customizable version that will allow you to make changes to it as you prefer.

The link to the customizable version will take you straight to Canva, a straightforward, user-friendly graphic design website where you can easily tweak this excellent report sheet to your preferred workflow.

Below is a YouTube video I found to be very helpful in giving you a step-to-step guide on how to customize your report sheet, just in case you are not familiar with Canva.

This is my holy grail nursing report sheet that I have used for some years now after I had gone through numerous nursing report sheet templates . I found during this experimenting stage that all the nurse brain sheets I used had many things I liked, but I wished I could change one or two things here and there to suit my workflow but could not.

This is why I am sharing and giving you the option to customize yours just like you like it.

If you are interested in learning more about nursing report sheet, and how you can leverage it to improve your productivity and work flow, keep reading!

Do you know what a nursing report sheet is? Have you ever wondered why nurses have different styles of report sheets? We will discuss the definition and purpose of a nursing brain sheet, how to make nursing report sheets that work for you, and finally, why every nurse needs their custom version of a brain sheet.

What is the purpose of a nursing report?

nursing report sheet

A nursing report is a system by which nurses communicate important patient information. This communication allows nurses to know their patient's conditions, medications, and treatments. The nursing report also alerts nurses to any potential problems that may need to be addressed.

Why is this important? 

nurse brain sheet

The exchange of information between nurses is critical for the safety and well-being of patients. Nursing report helps ensure that all nurses are aware of changes in a patient's condition and provide timely interventions if needed.

Why do nurses use report sheets?

nursing brain sheet

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.

If you are like me, you probably have too much going on during your shift and many patients to take care of to remember every single thing during shift change. 

Admitting and discharging patients in a single shift with multiple orders coming through within the hour, I know I cannot rely solely on my brain to remember everything, and I know I am definitely not alone on this table. This is why nurses need their nurse brain sheets for shift reports.

What should be included in a nursing report sheet?

Nurses Report sheet

The answer to this question depends on you as a nurse and the specialty you are working in. As a nursing student, a new nurse, or an experienced registered nurse, your sheet template should be designed according to your individualized workflow and specialty area.

Medical-surgical nurses' report sheets will have similar things to an ICU nurse's report sheet, but there will be some differences due to the difference in their specialty.

With that said, irrespective of your specialty and your personal preference, there are some key things that you should include on your report sheet to ensure patient safety and efficiency at work.

A nursing report sheet should include the following information:

Nurses Report Sheet Template

Patient Information

Patient's name, room number, age, sex, allergies, code status, date of admission, attending physician, and any other pertinent identifying data (i.e., identification numbers or barcodes).

Placing this critical patient information should be done strategically on the top page, where you can refer to it easily in case of any emergencies. For example, you definitely will want to know a patient's code status when there is a code.

You don't want to be the nurse scrambling through sheets to locate this information, and nor do you want to be the nurse who needs to refer to the EMR to find this information when a patient is in cardiac arrest.

Diagnosis/problems

Primary or admitting diagnosis, medical and surgical history, hospital course should be the next things to include. This should include critical diagnostic tests done in the emergency room and any other abnormal blood tests and findings before inpatient admission. It also should include all the essential noteworthy diagnostics and findings during the inpatient stage.

Vital signs

Always leave a section to include patients vital signs- blood pressure , pulse rate, respiratory rate & temperature. It will be best to have all vitals signs written down through your shift so you can take a quick look at them and see any changes and trends that you might need to keep an eye on. Although these vitals signs will always be on the EMR for referencing, having it right in front of you makes it easy to visualize a patient's condition trends.

Laboratory results

Critical lab results or diagnostic findings are definitely worth a spot on your nurse brain sheet. Not only will that make your life easy during shift change and help with patient care and safety, but it will help you visualize a whole picture of a patients health from which you can always base upon to make critical decisions when need be.

Please do not write down all lab results and diagnostics. Only write the relevant ones so you do not overcrowd your report sheet. You could include results like white blood cell counts, hemoglobin, hematocrit, BUN, creatinine, potassium, and many more that are relevant to the patients' care on that admission period.

Patient assessment findings

This is where you write down all the assessment findings during your time with the patient. Structure your report sheet to writ down assessment from heat to toe so you can have everything organized. For example, you can start with any findings from orientation to the head itself and then to the respiratory system, the cardiac system, then the GI system all the way down till you assess the entire body.

Current medications

You can also include medications that are noteworthy on your nurse brain sheet. I would not recommend writing all the medications a patient takes unless  its a handful which is not always so. I typically just write down important meds that are time sensitive- antibiotics, pain meds etc

Any pertinent notes

Always have a spot on your report sheet to write down things you need to communicate with the healthcare team. This spot is also good for noting down things you want to remind your self to do or tasks you will want to complete by the end of your shift.

The notes section will also be a good place to add all new orders and medication changes as well as discharge plan or plan of care so you can easily remember to pass it on to the oncoming nurse to ensure efficient continuity in care.

These are some of the basic things that every report sheet should have regardless of what specialty area you work in. Having all these info at one place will make it very easy to keep organized on your busy shift. When you have everything organized and planned out, it makes you very efficient. Plus, having a snap shot of your patients right in front of you will help you make good decisions when it comes to prioritizing care.

You will also have all of the pertinent information you will need for nurse handoff decreasing that shift hand off anxiety.

Why do you need a nursing brain sheet that works for YOU

nurse report sheet printable

When you're a nurse, there are so many things to keep track of- from patient information and medication administration to treatments and notes. And that's not even counting the other tasks you have to juggle on top of your nursing duties. Finding a report sheet that is especially tailored to your workflow makes it easy to keep sane and easily find all the vital information you will be needing to properly care for your patients. 

How can I make my own nursing report sheet?

make my own nursing report

There are many different ways to make your nursing report sheet. You can find templates online or create your custom design. 

Here are some tips on how to make a report sheet that works for you:

● Ensure the layout is easy to read and includes all the information you need.

● Include headings for each section, so it's easy to find information quickly.

● Use clear and concise language, so everyone who reads the report can understand it easily although no body might but just in case.

● Use diagrams such as the fishbone for visualize info like your lab reports, if needed.

● Print out a copy of the report sheet for every shift so you have it handy when you need it.

● Creating your nursing report sheet can be a great way to improve communication and patient care. By taking the time to create a sheet that works for you, you'll be able to work more efficiently and effectively during your shifts.

Is it important to write a nurse report?

Nurse reports are an essential communication tool between nurses, doctors, and other healthcare professionals. They can also help document the care that has been provided to a patient. Plus, they're just good for creating a record of what happened during your shift. It is therefore important as it will not only make you efficient as a nurse and improve communication, but more importantly, it can help improve patient care and safety. Grab a FREE copy on this article.

How do I write a good bedside report?

Use a template as attached above where there will be all the critical information you will need to know on your patient, or you can follow the guide above to make one afresh on Microsoft Word or on Canva if you know how to use it. Alternatively, you can just write everything on a blank paper.

Can I use any report sheet I want?

Yes, you absolutely can as long as it makes sense to you. Feel free to use any template or format that works best for you. Just be sure to include all the pertinent information you need to provide excellent care to your patient in an easy-to-read format.

What should I include on my report sheet?

The layout of your report sheet will vary depending on what information you need to track. Still, standard sections usually include patient name and ID number, important patient specific info, shift info, doctor's orders, medications and treatments given, vital signs, observations, and diagnosis and many more. You can use the reference above or use the FREE nurse report sheet attached in the beginning of this post.

How do I organize my nursing reports?

Nurses need an efficient way to record not only what happened during each shift/patient encounter but also any additional details they may have learned throughout the day. The easiest answer to this question is, organize it based on what makes sense to you or what you can easily make sense of. Just make sure to include all the above pertinent info.

I hope this article has helped you understand the importance of nurse report sheets. From making sure everyone knows what is going on to using it to track everything that occurred during your shift, these forms are essential for any nursing team. Download this customizable nurse report sheet  today and personalize its content according to YOUR needs instead of spending hours fumbling around trying to find just the right brain sheet online. Until we meet again on my nurse blog post, happy nursing!

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What’s Included on a Nursing Report Sheet?

Smiling young female nurse making report sheet

Nurses are the cornerstones of the healthcare industry, providing an essential link between physician and patient. One element that helps nurses maintain continuity of care for their patients are nursing report sheets (also known as nursing brainsheets). 

These sheets are typically produced for nursing colleagues at the change of shift.

In nursing school and clinicals, you need to know about creating and using nursing report sheets to provide the best possible care for patients (and to help your fellow nurses do the same after graduation).

What are Nursing Report Sheets?

Nursing report sheets (also known as patient report sheets or nursing brain sheets ) are templates nurses fill out with important patient information.

These sheets are handoffs at the end of each shift and are given to the new nurse taking over for the next shift. For example, if a nurse comes in for their night shift, they would get a nursing report sheet from the previous nurse finishing their shift. 

Nursing report sheets might also go with patients if they are being transferred to another hospital unit, such as from the pediatric unit to the ICU.

So, what goes on a nursing report sheet? The following bits of information are typically included:

  • Attending doctor
  • Records of medications
  • Medications to take during breakfast, lunch, and dinner
  • Important vital signs (e.g., temperature, heart rate, blood sugar, and blood pressure)
  • Basic patient information (e.g., name, date of birth, sex, and room)
  • Work nurses and doctors must perform for the patient during various shifts
  • Lab results and pending lab work
  • Future procedures
  • Additional notes about patient requests, and more

nurse reading

Why are Nursing Report Sheets (or Nursing Brain Sheets) Important?

A nursing report sheet provides essential directions on patient care to the incoming nurse – who might not be familiar with the patient and their medical needs – before change of shifts.

As a nurse, how does a nursing report sheet benefit you, your patients, and your colleagues?

  • Fast access to vital patient information
  • Better time management ability
  • Helps keep track of multiple different patients
  • Improves safety and care of patients
  • Increases the ease and accuracy of charting
  • Helps manage shift duties
  • Saves time and increases patient comfort
  • Serves as a legal document related to patient care

Nurses often refer to these sheets as their “brain” or nursing brain sheets — essential to keeping nursing life organized.

Nursing Brainsheets vs SBAR

Keep in mind that a nursing report sheet is different from an SBAR tool (situation, background assessment, recommendation tool). An SBAR tool includes important health history, an assessment of the patient’s current state, a briefing of recommended action, and so on. 

While the SBAR tool and a nursing report sheet are not the same, nurses use the SBAR tool to help guide the creation of the nursing report sheets.

What’s Included on a Nursing Report Sheet?

Just as there are different types of nurses in different health care units, there are also various types of nursing report sheets – which often have different organization styles and required information. 

Whether you plan to become a registered nurse, med surg nurse , or will need an ICU nurse report sheet, knowing how to create and utilize different styles of nursing brain sheets will be essential to success in your future career.

In detail, what can a new nurse expect to find on a nursing report sheet?

Basic Patient Info

Of course, you must know your patient’s name, age, and sex. Other basic patient information might include:

  • Admission date
  • Room number
  • Name of doctor(s)
  • Updated diagnosis
  • Allergies or sensitivities
  • Medical history (including pre-existing conditions or dangerous infections)
  • The patient’s code status
  • Advanced directives (such as DNR)
  • Power of attorney data
  • Living will information

Current Patient Health Info

The nursing report sheet must display the patient’s current vitals, most of which are recorded through regular nursing assessments .  Vitals help identify important statistics for different bodily functions, including cardiovascular blood pressure, temperature, oxygen levels, what the patient ate, etc.

Patient health information that is valuable for the next nursing shift includes:

  • Neuro information (such as the level of consciousness)
  • Musculoskeletal data (such as the patient being ambulatory or bedbound)
  • Patient dietary restrictions and other gastrointestinal or urinary considerations (such as whether they are incontinent or need a catheter)
  • Any wounds or pressure injuries on the skin
  • What medications the patient is taking
  • What IV access the patient has, and if they are getting continuous fluids (and if so, the type of fluids)

Ongoing Patient Care

As a nurse, you’ll provide medication or monitoring on a regulated basis that you’ll then record in the nursing report sheet. For example, a nurse might have to test the patient’s blood sugar at certain times during the day. Your brain sheet will help you determine if the results fall within normal lab values.

Some things you might find regarding ongoing patient care include:

  • What dosages of medications need to be administered, and when
  • If the patient requires certain tests that day
  • What to expect for normal test values for that patient
  • If the patient is supposed to be discharged at a certain time
  • If the patient is scheduled for future procedures that require preparation
  • The expected duration that patient may stay at your medical facility

Clearly, the nursing report sheet is there to help keep things organized so you never miss a beat.

Patient Notes

The patient notes explain things not fully covered in the nursing report sheet template. For example, if the patient hasn’t moved their bowels for a few days, you may wish to write a note as a reminder to discuss the situation with the medical team to see if a laxative or enema should be prescribed.

Read more about patient notes in our post about taking nursing notes .

Other patient notes you will likely find on your nursing report sheet include:

  • If the patient speaks a foreign language, and how to contact a translator.
  • Emergency contact information.
  • Any patient triggers or noteworthy care patterns.
  • Patient preferences, such as food choice or room temperature.
  • Patient routine reminders, such as needing to walk around 3x a day.

Special patient notes are generally discussed verbally with the incoming nurse to ensure proper patient care.

nurse discussing report

Take the Next Steps to Become a Nurse 

Staying organized as a nurse is vital to keeping your patient happy and healthy. A  nursing report sheet serves as the blueprint for everything someone would want to know about your patient – and you’ll find a lot of the elements above on many templates regardless of which nursing specialty you choose.

What’s on a nursing report sheet is just one of the many things you’ll want to know as you begin your journey as a nursing student. And you’ll need a supplemental tool for your lectures to ace your exams.

Access everything you need to know to pass your nursing school exams.

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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 sheet with organized patient information

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.

nurse report sheet for 6 patients

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.

Lab Values Diagrams

Specialized Report Sheets for Diverse Nursing Roles

Nursing.com report sheet

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

Nurse reviewing and printing a nursing report sheet template

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 for 6 patients

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.

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Nurse's Brain, Part 1: What is a Nurse's Brain? (Free Download)

by Cathy Parkes June 22, 2020 Updated: August 10, 2023 2 min read 9 Comments

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.

Want to get organized in nursing school?

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Full Transcript

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!

Cathy Parkes

Cathy Parkes

9 responses.

Diana Swayze

Diana Swayze

March 24, 2023

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

PCU-GRACE

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. :)

Taylor

May 25, 2022

I love this thank you so much!

Shawanda

February 08, 2022

An OB/ PEDS Brain sheet will be nice. This is my last semester in the LPN program.

HUGH

January 03, 2022

Would you kindly make a nurse’s brain sheet for maternity and pediatric please? Thank you!

Sharon

February 09, 2021

I am a new student nurse having my first clinical experiences. We did not get to have Clinicals last semester due to Covid so this is our first exposure. I have been trying to write a brain sheet myself and it’s just a hot mess! I’m so grateful to have your template. Thank you for taking the time to provide such a valuable tool.

Jill

August 05, 2020

Hi Cathy – thanks so much for sharing this. I am about to begin my first RN job and I’m a little nervous. However, being organized is a tactic I have used for many things in order to calm my nerves and feel confident. It will be so nice to have this for my patients!

LEON

July 06, 2020

Great tips and advices. You are the best! Thank you for sharing “The brain” : )

Kim

Cathy, this video and sample Nurse’s Brain is AWESOME!!! Thank you so much. I am a new graduate nurse and I used your videos and flashcards to study for the NCLEX and I passed! Now I am looking for more practical advice on how to survive as a new nurse on a med/surg floor. This video is PERFECT!! Thanks again and keep the great content coming!

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Psych Nurse Report Sheet 3 or 6-Patients

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Psych nurses: You'll love this template if you're looking for a way to organize your basic mental health assessments.

I made this custom sheet for a psych nurse, but I figured other psych nurses would also find this helpful! 3-patient report sheet to organize your notes for the shift--perfect for change of shift handoff. 6-patient sheet by printing back-to-back.

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6 Patient Nursing Report Sheet

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A Nursing Report Sheet is a document that should be completed by medical professionals to provide details for nursing their patients. This 6 patient report sheet is perfect for any medical, surgical or IMC unit. It has 2 pages, with a time log on the back to keep track of important tasks.

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2-page 6 Patient Nursing Report Sheet in PDF and PNG Format in 3 sizes (A4, US Letter, A5) and in 6 Colors.

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Fact Sheet 42 CFR Part 2 Final Rule 

Date: February 8, 2024

On February 8, 2024, the U.S. Department of Health & Human Services (HHS) through the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office for Civil Rights announced a final rule modifying the Confidentiality of Substance Use Disorder (SUD) Patient Records regulations at 42 CFR part 2 (“Part 2”). With this final rule, HHS is implementing the confidentiality provisions of section 3221 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (enacted March 27, 2020), which require the Department to align certain aspects of Part 2 with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Rules and the Health Information Technology for Economic and Clinical Health Act (HITECH).

The Part 2 statute (42 U.S.C. 290dd-2) protects “[r]ecords of the identity, diagnosis, prognosis, or treatment of any patient which are maintained in connection with the performance of any program or activity relating to substance use disorder education, prevention, training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or indirectly assisted by any department or agency of the United States.” Confidentiality protections help address concerns that discrimination and fear of prosecution deter people from entering treatment for SUD.

The modifications in this final rule reflect the proposals published in the December 2, 2022, Notice of Proposed Rulemaking (NPRM) and public comments received from: substance use disorder and other advocacy groups; trade and professional associations; behavioral and other health providers; health information technology vendors and health information exchanges; state, local, tribal and territorial governments; health plans; academic institutions, including academic health centers; and unaffiliated or anonymous individuals. Following a 60-day comment period, HHS analyzed and carefully considered all comments submitted from the public on the NPRM and made appropriate modifications before finalizing.

Major Changes in the New Part 2 Rule

The final rule includes the following modifications to Part 2 that were proposed in the NPRM:

  • Allows a single consent for all future uses and disclosures for treatment, payment, and health care operations.
  • Allows HIPAA covered entities and business associates that receive records under this consent to redisclose the records in accordance with the HIPAA regulations. 1
  • Permits disclosure of records without patient consent to public health authorities, provided that the records disclosed are de-identified according to the standards established in the HIPAA Privacy Rule.
  • Restricts the use of records and testimony in civil, criminal, administrative, and legislative proceedings against patients, absent patient consent or a court order.
  • Penalties : Aligns Part 2 penalties with HIPAA by replacing criminal penalties currently in Part 2 with civil and criminal enforcement authorities that also apply to HIPAA violations. 2
  • Breach Notification : Applies the same requirements of the HIPAA Breach Notification Rule 3 to breaches of records under Part 2.
  • Patient Notice : Aligns Part 2 Patient Notice requirements with the requirements of the HIPAA Notice of Privacy Practices.
  • Safe Harbor : Creates a limit on civil or criminal liability for investigative agencies that act with reasonable diligence to determine whether a provider is subject to Part 2 before making a demand for records in the course of an investigation. The safe harbor requires investigative agencies to take certain steps in the event they discover they received Part 2 records without having first obtained the requisite court order.

Substantive Changes Made Since the NPRM

In addition to finalizing modifications to Part 2 that were proposed in the NPRM, the Final Rule includes further modifications informed by public comments, notably the following:

  • Safe Harbor: Clarifies and strengthens the reasonable diligence steps that investigative agencies must follow to be eligible for the safe harbor: before requesting records, an investigative agency must look for a provider in SAMHSA’s online treatment facility locator and check a provider’s Patient Notice or HIPAA Notice of Privacy Practices to determine whether the provider is subject to Part 2.
  • Segregation of Part 2 Data : Adds an express statement that segregating or segmenting Part 2 records is not required.
  • Complaints : Adds a right to file a complaint directly with the Secretary for an alleged violation of Part 2. Patients may also concurrently file a complaint with the Part 2 program.
  • SUD Counseling Notes : Creates a new definition for an SUD clinician’s notes analyzing the conversation in an SUD counseling session that the clinician voluntarily maintains separately from the rest of the patient’s SUD treatment and medical record and that require specific consent from an individual and cannot be used or disclosed based on a broad TPO consent. This is analogous to protections in HIPAA for psychotherapy notes. 4
  • Prohibits combining patient consent for the use and disclosure of records for civil, criminal, administrative, or legislative proceedings with patient consent for any other use or disclosure.
  • Requires a separate patient consent for the use and disclosure of SUD counseling notes.
  • Requires that each disclosure made with patient consent include a copy of the consent or a clear explanation of the scope of the consent.
  • Fundraising : Create a new right for patients to opt out of receiving fundraising communications.

What has not changed in Part 2?

As has always been the case under Part 2, patients’ SUD treatment records cannot be used to investigate or prosecute the patient without written patient consent or a court order.

Records obtained in an audit or evaluation of a Part 2 program cannot be used to investigate or prosecute patients, absent written consent of the patients or a court order that meets Part 2 requirements.

What comes next?

The final rule may be downloaded at https://www.federalregister.gov/public-inspection/2024-02544/confidentiality-of-substance-use-disorder-patient-records . HHS will support implementation and enforcement of this new rule, including through resources related to behavioral health developed by the SAMHSA-sponsored Center of Excellence for Protected Health Information . Persons subject to this regulation must comply with the applicable requirements of this final rule two years after the date of its publication in the Federal Register . The Department will conduct outreach and develop guidance on how to comply with the new requirements, such as filing breach reports when required.

OCR plans to finalize changes to the HIPAA Notice of Privacy Practices (NPP) to address uses and disclosures of protected health information that is also protected by Part 2 along with other changes to the NPP requirements, in an upcoming final rule modifying the HIPAA Privacy Rule.

HHS planning to implement in separate rulemaking the CARES Act antidiscrimination provisions that prohibit the use of patients’ Part 2 records against them.

1   However, these records cannot be used in legal proceedings against the patient without specific consent or a court order, which is more stringent than the HIPAA standard.

2    See 42 U.S.C. 1320d–5 and 1320d-6.

3   Section 13400 of the HITECH Act (codified at 42 U.S.C. 17921) defined the term “Breach”. Section 13402 of the HITECH Act (codified at 42 U.S.C. 17932) enacted breach notification requirements, discussed in detail below.

4    See https://www.hhs.gov/hipaa/for-professionals/faq/2088/does-hipaa-provide-extra-protections-mental-health-information-compared-other-health.html .

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COMMENTS

  1. The Ultimate Nursing Report Sheet Guide

    FREE DOWNLOADS! - 10 Nursing Report Sheets & Templates with SBAR and Brain format: Perfect for Med-Surg, ICU, Tele, Step-Down, and ER units. About; Free Nursing Report Sheets; ... 6. Brain Nursing Report Sheet. 1 patient per sheet; Brain format; Great for all units; 7. 2 Patient Landscape Nurse Report Sheet. 2 patients per sheet;

  2. PDF NURSING BRAINSHEETS 33 Brainsheet Database

    HANDOFF AND REPORT SHEET ... Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets VERTICAL PATIENTS BRAINSHEETS Labs: Pain: Pt: Age: Rm# RN: Dx: FSBS: Coverage: T O2 RR B/P /10 /10 K-Na-PO IV x0700 x0800 x0900 x1000 x1100 x1200 x1300 IV RATE NOTES Labs:

  3. NurseMind's Brain Museum

    NurseMind's Brain Museum. General-purpose. By Elizabeth Eckard (thank you!), a med/surg nurse on the Neuro/Ortho Floor at Hershey Medical Center. One patient. Many nursing assessments. General-purpose. Day shift. By a nurse who floats among med-surg, telemetry, ortho, etc.

  4. Ultimate Nursing Report Sheet Database & Free Downloads

    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.

  5. What is a Nursing Report / Brain Sheet? + Free Templates!

    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 ...

  6. Nursing Report Sheet Templates

    Helps you keep your charting more accurate. If you write down on your report sheet things you need to remember to chart, your charting will be more accurate and easier to do. Again with 6 to 7 patients things tend to run together. Nursing Report Sheets (Templates) Below are free for your to download nursing report sheet templates. You can print ...

  7. FREE Nursing Report Sheets & How to Make One

    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).

  8. NurseTasks

    10 free nurse report sheet templates with PDFs and editable Docx files included. 1-4 patients per sheet, portrait and landscape options available. Perfect for med-surg, ICU, tele, step-down, and ER units ... Four Patient Nurse Report Sheet. 4 patients per sheet. SBAR format. Great for med surg and tele units. 6. Brain Nursing Report Sheet. 1 ...

  9. Brain Sheets

    The brain sheet is then used at the end of shift to give report to the oncoming nurse. Having a good brain sheet is key for patient safety and effective communication. ️ Click to get report sheets for ICU, Med Surg and Telemetry. Need more info on how use a brain sheet for report? Here's what a Med-Surg brain sheet looks like at the beginning ...

  10. 5 Best Nursing Report Sheets & Notebooks

    Additional Info. The notebook is convenient to carry, measuring approximately 15.2 x 14.5 cm/ 5.98 x 5.71 inches, making it a proper size to put in your pocket, gown, or bag, saving space for you. #3. Nursing Brain Sheet Multiple Patient Notebook. CHECK PRICE HERE.

  11. Nursing Report Sheet & Example

    Keep a secure record of patient information. The Nursing Report Sheet is an easy way to store patient information in a secure, confidential manner. It can help you monitor important information and provide quick access to the data if needed. ... Benefits of free Nursing Report Sheet. This free Nursing Report Sheet is a fantastic resource for ...

  12. A Budding Nurses' Guide to Nursing Report Sheets: With Free

    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. If you are like me, you probably have too much going on during your shift and many patients to take care of to remember ...

  13. Essential Elements of a Nursing Report Sheet Nurse Guide

    Nursing report sheets (also known as patient report sheets or nursing brain sheets) are templates nurses fill out with important patient information. These sheets are handoffs at the end of each shift and are given to the new nurse taking over for the next shift. For example, if a nurse comes in for their night shift, they would get a nursing ...

  14. 18 Free Nursing Report Sheets (Templates)

    The nursing report sheet is also known as a patient report sheet, an end-of-shift report, or a nursing brain sheet. It is vital for helping nurses monitor their patients when their shifts change. When nurses arrive for their shifts, they are given a report sheet from the nurses finishing their shifts. Thus, the report sheet is a concise and ...

  15. Nurse Brain: Creating Your Nursing Report Sheet

    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 ...

  16. How to Give an End-of-Shift Report to Another Nurse

    A Nurse's Brain, also known as a nursing report sheet, is a term for a sheet of paper that nurses use to capture important patient information and stay organized. It contains sections for key areas like patient history, diagnoses, labs, medications, body systems status, and more.

  17. Nurse Report Sheet for 3 or 6 Patients, Med Surg Nurse Report Sheet

    The perfect med surg nurse report sheet will help you stay organized & prioritize patients during a busy shift. 6-patient nurse report sheet by printing back-to-back. Includes an hourly to-do list to further organize your day - keep track of meds, treatments, vitals, assessments & notes -- all necessary info for handoff. ...

  18. What is a Nurse's Brain sheet and how do you use it?

    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.

  19. Nurse Report Sheet for 4 or 8 Patients, Med Surg Nurse Report Sheet

    4 or 8-Patient Medical Surgical Nurse Report Sheet & Medication Schedule | Nurse Brain. Instant download PDF file. 4-patient nurse report sheet to help you organize & prioritize patients during a busy shift. 8-patient report sheet by printing back-to-back. Includes a medication schedule to keep track of meds for up to 4 patients. Includes: 0700 ...

  20. Give report confidently with this nursing report sheet template

    THE BEST Printable Nursing Report Sheet on the internet. Your days of stumbling through SBAR + end of shift report —are over. FOR LICENSED NURSES (Including sheets for Med-Surg, PCU, ICU, ER, OB & other departments!) Email me the FREE Printable Report Sheet Your Info Is 100% Safe.

  21. Psych Nurse Report Sheet 3 or 6-Patients

    Psych Nurse Report Sheet 3 or 6-Patients | Mental Health Nurse Instant download PDF file Psych nurses: You'll love this template if you're looking for a way to organize your basic mental health assessments. I made this custom sheet for a psych nurse, but I figured other psych nurses would also find this helpful! 3-pati

  22. Nursing Report Sheet 6 Patients

    6 Patient Nurse Report Sheet Med Surg Bundle, Multiple Patient Report Sheet RN Nursing ICU Nurse Brain W/ Medication & To-Do, New Grad Nurse (1.3k) Sale Price $3.00 $ 3.00 $ 5.99 Original Price $5.99 (50% off) Sale ends in 10 hours Add to Favorites ...

  23. 6 Patient Nursing Report Sheet

    A Nursing Report Sheet is a document that should be completed by medical professionals to provide details for nursing their patients. This 6 patient report sheet is perfect for any medical, surgical or IMC unit. It has 2 pages, with a time log on the back to keep track of important tasks. What is included in your purchase?

  24. Fact Sheet 42 CFR Part 2 Final Rule

    Fact Sheet 42 CFR Part 2 Final Rule Date: February 8, 2024. On February 8, 2024, the U.S. Department of Health & Human Services (HHS) through the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office for Civil Rights announced a final rule modifying the Confidentiality of Substance Use Disorder (SUD) Patient Records regulations at 42 CFR part 2 ("Part 2").