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Nursing Report Sheet: Free Template and Completed Example

The ScribeMD Team ·

It's 1855. Day shift is packing up, and in five minutes you'll be standing at the station taking report on five patients you've never met. One is a fresh post-op, one is confused overnight, one is waiting on a CT read. By 1930 you need to know who to see first, what's due when, and what the last nurse was worried about.

That's what a nursing report sheet is for. Nurses also call it a brain sheet, a shift report sheet or a handoff sheet. It's the folded page in your pocket that holds the shift together. This guide covers what belongs on one, a fill-in nursing report sheet template you can copy, a completed example, and how to adapt the layout for your unit.

The patient in the example is invented. Follow your facility's policies and the prescriber's orders for actual care.

What is a nursing report sheet?

A nursing report sheet is a personal working tool for organizing patient information during a shift. You fill it in while taking report, update it as orders, vitals and results come in, and use it to give a clean report at the end of your shift.

Two things it is not:

  • It's not the legal record. Assessments, medications given and interventions still get documented in the EHR. The report sheet helps you remember. The chart is what counts.
  • It's not a handoff format on its own. Many units pair the sheet with a structured verbal handoff such as SBAR. The sheet holds the data and SBAR gives the report its order. See our SBAR template and examples for that side of handoff.

What to include on a nursing report sheet

Every unit tweaks the layout, but most good report sheets cover the same ground:

  • Patient identifiers: name, room, age, admit date, attending or covering team.
  • Code status and isolation: placed where you'll see them first.
  • Allergies.
  • Admitting diagnosis and relevant history: why they're here and the history that changes how you care for them.
  • Systems assessment: neuro, cardiac, respiratory, GI/GU, skin, pain, mobility. Leave room to note the baseline and what changed.
  • Lines, drains and airways: IV sites, catheters, drains, oxygen device.
  • Vital sign trends: a few columns across the shift, so you see direction, not just one value.
  • Labs and diagnostics: pending results, abnormal values and anything you need to call about.
  • Medication times: scheduled due times and the last time any as-needed medication was given. Keep the details in the MAR, not on paper.
  • Diet, activity and safety: NPO status, fall risk, restraints or sitter, aspiration precautions.
  • Hourly to-do grid: a timeline for the shift (turns, reassessments, labs, dressing changes).
  • Plan and discharge needs: what has to happen before the next report, consults, teaching, case management.

Nursing report sheet template

Copy this into a document, print one per patient (or one column per patient on med-surg), and cross out what your unit doesn't use.

  • Patient: Room ___ | Name ___ | Age ___ | Admit date ___ | Attending/team ___
  • Code status: ___ | Isolation: ___ | Allergies: ___
  • Diagnosis: ___ | Relevant history: ___
  • Neuro: orientation, baseline mental status, changes ___
  • Cardiac: rhythm, edema, telemetry ___
  • Respiratory: lung sounds, oxygen device, cough ___
  • GI/GU: diet, last BM, voiding or catheter, intake and output ___
  • Skin: wounds, incisions, pressure areas ___
  • Pain: score, location, last as-needed medication time ___
  • Mobility and safety: activity level, assist, fall risk, precautions ___
  • Lines, drains, airways: ___
  • Vitals trend: 2000 ___ | 0000 ___ | 0400 ___
  • Labs and diagnostics: pending ___ | abnormal ___
  • Medication due times: ___
  • To do this shift: ___
  • Plan and discharge needs: ___
  • Concerns to pass on: ___

Completed nursing report sheet example

Here's the same template filled in for one patient on a med-surg night shift.

  • Patient: Room 412 | J.M. | 72 | Admitted yesterday | Hospitalist team B
  • Code status: Full code | Isolation: None | Allergies: Penicillin (rash)
  • Diagnosis: Community-acquired pneumonia, right lower lobe | Relevant history: Type 2 diabetes, COPD, lives alone
  • Neuro: Alert and oriented x4 on day shift. Baseline per daughter: fully oriented. Watch for confusion overnight.
  • Cardiac: Sinus rhythm, no edema.
  • Respiratory: Crackles right base, productive cough. On 2 L nasal cannula, sats 92-94%. Goal range per order.
  • GI/GU: Diabetic diet, eating about half of meals. Voiding. Last BM yesterday.
  • Skin: Intact. Reddened sacrum, blanchable. Turn every 2 hours.
  • Pain: 3/10 pleuritic chest pain. Last as-needed analgesic at 1700.
  • Mobility and safety: Up with 1 assist and walker. High fall risk. Bed alarm on.
  • Lines, drains, airways: Peripheral IV left forearm, day 2, no redness.
  • Vitals trend: 1600: T 38.1, HR 98, RR 22, BP 128/74. 1900: T 37.6, HR 90, RR 20.
  • Labs and diagnostics: Blood cultures pending. Morning CBC and BMP ordered. Fingerstick glucose before meals and at bedtime.
  • Medication due times: IV antibiotic due 2200. Scheduled inhaler 2000.
  • To do this shift: Bedtime glucose. Reassess pain after 2000 meds. Incentive spirometer teaching (did 3 of 10 reps on days).
  • Plan and discharge needs: Possible switch to oral antibiotics if afebrile 24 hours. Case management to assess home support.
  • Concerns to pass on: Daughter worried about confusion at night. Call the provider for new confusion, sats below the ordered goal, or a rising temperature.

Notice what makes it useful: baselines are written next to current findings, every pending item has a time, and the concerns line tells the next nurse what to watch for rather than just what happened.

Adapting the report sheet to your unit

Med-surg

You'll carry four to six patients, so a one-column-per-patient layout on a single page often works best. Put discharge status, pain reassessment times and dressing changes where you can scan them quickly.

ICU

Fewer patients, far more data. Give each patient a full page with space for ventilator settings, drips, hourly intake and output, sedation scores, and lines with insertion dates.

Emergency department

Turnover is fast. Keep it short: chief complaint, time of onset, triage level, pending studies, and disposition (admit, transfer, discharge).

Pediatrics

Put weight in kilograms at the top, along with age-appropriate vital sign ranges, the pain scale you're using, the caregiver at the bedside and feeding or diaper counts.

Tips for a report sheet you'll actually use

  1. Start from a template, then edit it. Use a sheet for a week. Add the fields you kept hunting for and remove the ones you never filled in.
  2. Write trends, not snapshots. "HR 98 to 90" tells the next nurse more than "HR 90."
  3. Mark what's pending. A circle or star next to labs, consults and callbacks keeps them from falling through the cracks at shift change.
  4. Chart from the sheet promptly. The sheet holds notes for a few hours. Get findings and interventions into the EHR as you go, not at 0645.
  5. Protect it. It holds patient information. Keep it on you, don't leave it at the station, and put it in the confidential shred bin before you leave.

Once the report is given, the plan behind it still needs to live in the chart. Our nursing care plan template covers that part.

Where an AI scribe fits

A report sheet is a personal, minute-to-minute tool, and it should stay that way. The documentation around it is a different matter. Admission histories, patient and family conversations and visit notes take a lot of typing, and that's where an AI scribe can help. It listens to the conversation and drafts the note, so you start from what was actually said instead of a blank screen.

The tradeoffs are real. Patients need to know the conversation is being recorded and consent according to your organization's policy. Every draft has to be reviewed, corrected and signed by you, and you can expect to edit more in the first weeks while the templates are set up. ScribeMD is HIPAA and SOC 2 compliant, works in more than 30 languages, integrates with 35+ EHRs and produces a draft note in under 30 seconds.

If you'd like to see how ScribeMD turns a clinical conversation into a draft note you review and sign, book a demo.