5 Nursing Report Instrument Tool

A quick comprehensive nursing report is important to excellence in patient care. Use this Nursing Report Tool to help guide your nursing report to give a quick concise comprehensive nursing report.

Quick Comprehensive Patient Report Tool

When reporting off on your patient for transfer of care use the

SBAR TOOL to assist you.

Situation, background, assessment, recommendation

A comprehensive report may include the following:

• Patients name, age

• Hx of admission/diagnosis

• Code status

• Abnormal occurrences

• Isolation precautions if applicable

• Allergies

• Vital signs

• Mental status/ any changes

• Systems: lungs, heart, GI, skin (more comprehensive prn)

• Abnormal labs

• Tests treatments, pending labs

• IV size, location

• Fluid status/ I&O

• Changes in plan of care (ie, to ICU)

• Meds given/ time

• Teaching- would include family

• Drains wounds dressing status

• Provider notified

(D. Driscoll 2016)