Vitals
| Time | |||
|---|---|---|---|
| BP | |||
| HR | |||
| RR | |||
| Temp | |||
| SpO₂ | |||
| Pain |
Meds due
| Time | Med |
|---|---|
To do
Tell the next shift
Vitals
| Time | |||
|---|---|---|---|
| BP | |||
| HR | |||
| RR | |||
| Temp | |||
| SpO₂ | |||
| Pain |
Meds due
| Time | Med |
|---|---|
To do
Tell the next shift
Ask at report
Code status Allergies Why they are here, plan for today Last vitals, anything off Lines, drips and rates Pain: last dose and time Meds due in the next two hours Labs or tests pending Fall risk, alarms, sitter Diet, voiding, last BM Family: who to call Going home soon?Who to call
Charge nurse Preceptor Rapid response Provider on call Pharmacy Lab Tech on my patientsWords to look up
Ask my preceptor
Who this sheet is for
New graduate nurses in the first weeks on a unit, with one or two patients and a preceptor. It is a simpler brain sheet with the things nobody tells you to write down.
The two patient blocks on the left are for report and the shift: why they are here, code status, vitals three times, meds due and a short to-do list. The checklist on the right is for report itself. Tick each item as you hear it, and ask about the ones nobody mentioned.
Fill in the phone numbers on your first day and keep the sheet: the charge nurse, rapid response, pharmacy and the provider on call are the calls you will make most. Write down the words and abbreviations you did not know, and the questions for your preceptor, so they get answered before the end of the shift.
Blocks worth knowing
- Ask at report
- the questions that are easy to forget when report is fast
- Who to call
- numbers and extensions for your unit, filled in once
- Words to look up
- abbreviations and unit habits you will hear on day one
It prints on one US Letter page and comes as a free PDF with no sign-up. It is blank working paper, not a medical record: shred it at the end of the shift. Compare all the sheets or build your own layout.