Hello All!
As I begin preparing for my last semester of clinical, I decided to be proactive and try my hand at true reporting. My first semester of clinical I used a clipboard with lose leaf and instructor hand outs clamped in. I carried that around with me on each unit until one instructor took my clipboard from me for the day and told me that it was bulky and would get in everyone's way. After that experience, I changed tactics and simply used a mini notebook I could slip in my scrubs pocket. It was certainly more compact but I was limited on space.
My third semester of clinical was OB/Peds and my instructors gave us individual folders and report hand outs each week that we used to write down our information. This was appreciated because of the intense specialties of OB and pediatrics.
During my first round of my last semester I used a combination of both paper and a mini notebook. I quickly discovered that with the specialty I was in, and with the information my instructor wanted me to know, a mini notebook just wouldn't cut it. However, I would use the mini notebook how I used it for all of my other units - quickly jotting down vitals.
During my CRT experience, the last few weeks of the semester I only had to bring that little notebook because I was literally only charting vital signs. With the unit I was on, there was no intense charting that needed to be done, and the only assessment that was conducted was vital signs.
Now that I have the opportunity to enter the same specialty unit again for my normal clinical time I figured that this would be a as good a time as any to try out my own report sheet usage, similar to what every nurse uses. I began my "research" by looking up nursing Youtube videos, searching for someone who wanted to talk about their own report sheet. (I KNOW, I'M WEIRD) I didn't find much, and discovered I wanted something I could just print out and try.
The next step in my report sheet journey was looking to Pinterest and Google to find free downloadable report sheets. My criteria for one was it needed to have ample space for my giant handwriting, clear space for multiple vital records, and room for notes or medication lists. The materials I found on the internet were impressive, but there wasn't one that compiled everything I was personally looking for.
I won't list the different sites I found with report sheets, a simple google search of the topic will bring up a lot of results. There are a lot that are categorized by nursing specialty.
Not finding what my little heart truly desired in a mapped out sheet of paper, I decided to take my dorkiness to the very next level. I created my own. I took inspiration from a lot of different report sheets that I discovered on my search, creating what I believed to be the best of many worlds.
The process didn't take long at all, and I feel fairly content with what I have created. I also typed out a user friendly SBAR sheet. (I found that on Pinterest but the Pinterest post was a picture of someone's copy, which wouldn't have been usable to write on.) I think that this SBAR sheet will act as an amazing prep piece before you make the dreaded physician phone call. I have honestly never had the opportunity to call a physician before, so I know that when I make that first call as a nurse I will be extremely nervous. Also, I am not one to tell a very streamline story that gets to the point - and that's exactly what they want. This document allows you to fill in the blanks of the narrative and will maybe let you sweat less when you're on the line with the doc.
Below I am attaching pdf files of each document, to which you can download and print to your heart's content if you feel as though it will work for your clinical days. I recommend printing double sided for convenience and the environment. (Us nursing students go through enough paper as it is!)
I hope that this information and resources make your clinical days go by more smoothly!
- Michelle
#BSNbabe
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