Nursing Report Sheet

Nursing report sheet is a patient care record maintained by healthcare staff during routine monitoring and assessment. It is used by nurses, doctors, and other healthcare providers to communicate patient status, coordinate care, and ensure smooth transitions during handoffs, transfers, and medical reviews.

This sheet can be used to document quick updates such as admitting diagnosis and care instructions in real time. You can also record vital signs, lab results, and clinical observations in areas such as neurology, respiratory status, cardiac function, skin condition, and mobility for better clinical decisions.

How to Use This Sheet

Each section of this sheet is formatted to capture essential clinical and patient care information. The following guide explains how to document each field accurately for safe handoffs.

Initial Information

This section is intended to gather the patient’s basic information and current health situation at the time of admission. You should always verify this information directly with the patient, their ID band, or the official chart to minimize errors.

Document the patient’s age and biological sex, which often influence medical decisions and risk factors. You should also record their code status (e.g., Full Code, DNR), which informs the team how to respond during emergencies. Document any allergies, especially to medications, food, and materials like latex. Also indicate if the patient is under any isolation precautions and specify the type (contact, droplet, airborne), as this directly affects infection control measures and can prevent life-threatening reactions.
Record the mobility status of patients based on the latest assessment (e.g., independence, needs assistance, bedrest) for safe movement and fall prevention.

Vitals

Vital signs and observations involve consistent monitoring of key physiological functions. These include temperature (Temp) to detect fever or hypothermia, oxygen saturation (SpO₂) to assess respiratory function, and blood pressure (BP) for monitoring potential signs of shock, hemorrhage, or cardiac instability. Record pain levels to evaluate patient comfort and guide appropriate interventions. You should also document other relevant observations, such as level of consciousness and any changes in skin color, depending on the patient’s condition. Noting trends over time can help with detecting any abnormal or concerning changes and should be escalated to the clinical team.

Lab results

The sheet includes space to record results from a variety of lab categories, including hematology, coagulation, electrolytes, kidney function, cardiac markers, and glucose levels.

Examples of key labs:

• Hematology (e.g., WBC, hemoglobin) – to assess for infection or anemia
• Coagulation (e.g., PT, PTT, INR) – especially important for patients taking blood thinners or at risk of clotting or bleeding
• Electrolytes (e.g., Na, K, Ca, Mg) – critical for cardiac, neurological, and muscular function
• Renal Function (e.g., BUN, Creatinine) – to evaluate kidney performance
• Cardiac Markers (e.g., BNP, Troponin) – used in cases of suspected heart failure
• Blood Sugar (e.g., Accu-Chek) – for monitoring glucose levels, especially in diabetic patients

You should use clinical judgment to decide which lab results are relevant to document based on the patient’s condition and overall status.

Clinical Assessment

In this section, briefly document key findings across the neurological, respiratory, and cardiac systems, noting any changes in consciousness, orientation, respiratory rate or effort, heart rate, rhythm, or blood pressure. Include relevant observations from the gastrointestinal and urinary systems, such as abdominal discomfort, nausea, changes in bowel habits, or urinary output. Assess the skin for integrity issues, including wounds, pressure areas, rashes, or unusual temperature or color changes. Additionally, evaluate for signs of venous thromboembolism (VTE), such as limb swelling, tenderness, or redness that could indicate a developing blood clot. Concise, insightful documentation is essential to highlight any deviations from the patient’s baseline condition.

Schedule Procedures and Schedule Consultant

The “Schedule Procedures” field is used to document any planned medical interventions. Record this when a procedure (e.g., imaging, surgery, lab work) is ordered by a consultant. Include the procedure name, scheduled date and time (if known), and any relevant notes for timely coordination with other departments and healthcare providers.

Additionally, any requests for evaluations from other healthcare specialists involved in the patient’s care should be mentioned in the “Schedule Consultant” field.

Discharge

This section marks the final step in the patient’s on-site care. Check the appropriate box to indicate the discharge plan—whether the patient is going home, will receive home health services, or is being transferred to a skilled nursing facility (SNF).