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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
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.
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.
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.