Nursing Report Sheet: What to Include (Free Template)

You take report on five patients in fifteen minutes. By mid-morning, you’ve given meds, answered call lights, and fielded two new orders. Without a system, something will slip. That’s what a nursing report sheet is for: one page that holds everything you need to know about your patients, so your memory doesn’t have to.

This guide covers what to include on a nurse report sheet, how to use it through a shift, how ICU and med-surg sheets differ, and a copy-ready template.

It’s a one-page sheet nurses use to track each patient’s key details and tasks through a shift.

A nursing report sheet, also called a nurse report sheet or brain sheet, is a personal working tool. Nurses fill it in while receiving report at the start of a shift, update it as the day goes on, and use it to give report at the end.

It is not the official medical record. Assessments, medications, and care still need to be documented in the EHR. The report sheet is where you organize your shift; the chart is where you document it.

It keeps critical details in one place, so nothing gets missed during a busy shift or at handoff.

Handoffs are one of the riskiest moments in patient care. The Joint Commission has estimated that 80% of serious medical errors involve miscommunication between caregivers during patient handoffs. A report sheet helps on both ends of the shift:

• At the start, it gives you a structure for taking report, so you ask about the same essentials for every patient.
• During the shift, it shows what’s due and when, in one glance.
• At the end, it becomes your script for giving a complete, organized report.

For the full handoff process, see our guide to nurse shift handovers.

Patient basics, safety alerts, a systems assessment, lines, meds, labs, and the plan for the shift.

Fill it in during report, update it as the shift goes, and use it to give report at the end.

1. Before report: print or prepare one sheet (or one section) per patient.
2. During report: fill in each section as the off-going nurse talks. Note anything unclear and ask about it before they leave.
3. Plan your shift: use a time column to block out med passes, assessments, labs, and procedures hour by hour.
4. Update as you go: cross off completed tasks and add new orders, results, and changes in condition.
5. Give report: walk through the sheet section by section. A structured format like SBAR keeps it consistent. Our SBAR handover how-to and template walks through it step by step.

The core is the same, but ICU, med-surg, and pediatric sheets each emphasize different details.

What goes on an ICU report sheet?

ICU sheets track fewer patients in more detail: drips, ventilator settings, and frequent vitals.

ICU nurses usually care for one or two patients, so an ICU report sheet goes deeper:

• Drips and titrations: each infusion, its rate, and the titration parameters
• Ventilator or oxygen settings, and recent blood gases
• Frequent vital signs and hemodynamic monitoring
• Lines and devices: central lines, arterial lines, chest tubes, drains
• Sedation and neuro checks

What goes on a med-surg report sheet?

Med-surg sheets fit several patients on one page, with medication times and tasks up front.

Med-surg nurses typically care for more patients at once, so a med-surg report sheet needs to be compact:

• One row or box per patient, with the essentials at a glance
• Medication and task times in a grid across the shift
• Fall risk, mobility, and diet flagged clearly
• Discharge planning notes, since turnover is high

Pediatric sheets add weight-based details and family or caregiver contacts.

Yes. Copy the template below, then adapt the sections to your unit and your patients.

NURSING REPORT SHEET

Patient:
Room:
Age:
Diagnosis:
Attending:
Code status:
Allergies:
Isolation:
Fall risk:

HISTORY:

VITALS (latest / trend):

ASSESSMENT
  Neuro:
  Cardiac:
  Respiratory:
  GI / GU:
  Skin:
  Pain:

LINES / DRAINS / AIRWAY:

IV FLUIDS / DRIPS (rate, next bag due):

MEDICATIONS (times):

LABS / PENDING TESTS:

DIET / ACTIVITY:

PLAN / TO-DO:
  [ ]
  [ ]
  [ ]

HOURLY PLAN
  07:
  09:
  11:
  13:
  15:
  17:
  19:

How do you make your own report sheet?

Start from a template, keep the sections in the order you assess, and test it for a few shifts.

Many nurses build their own sheet in a document editor, a spreadsheet, or a design tool. Whatever you use:

• Order sections the way you think, for example head-to-toe, matching your assessment.
• Leave room for the hourly plan; it’s what makes a sheet useful mid-shift.
• Keep it to one page per patient (or one row per patient for larger assignments).
• Test it for a few shifts, then cut what you never use and add what you keep writing in the margins.

Treat it as patient information: keep it with you, never photograph it, and shred it after.

A report sheet contains protected health information (PHI). Under the HIPAA Privacy Rule, healthcare organizations must have reasonable safeguards to protect it, and your hospital will have its own policy on paper patient information. In practice:

• Keep it on you, not on counters or in break rooms.
• Never photograph it or copy it into personal apps.
• Don’t take it home. Shred it in a secure bin before you leave.
• Use minimal identifiers if your unit’s policy allows, such as room number and initials.

The big ones are vague notes, outdated info, and treating the sheet as the official record.

• Vague notes: “Labs pending” doesn’t tell you which labs or when.
• Outdated information: a sheet that isn’t updated becomes a risk at handoff.
• Unclear abbreviations: shorthand only you understand, or error-prone abbreviations, can cause confusion when you give report. See medical terminology miscommunication.
• Treating it as documentation: anything important still belongs in the EHR.
• Skipping the safety alerts: code status, allergies, and isolation should never be blank.

Keep one consistent layout, fill it in during report, and update it as the shift goes.

The less time you spend searching your sheet, the more time you have for patients. Use the same layout every shift, so your eyes know where to look. Update it in small moments throughout the day rather than all at once at the end.