A nursing shift report hands a patient from the nurse going off shift to the nurse coming on: how sick they are, what changed, what is due, and what to do if things go wrong. Copy the free template, built on I-PASS, see a telemetry patient with a new fast heart rate and a post-op patient going home, and check what to say in each part.
Blank nursing shift report template
FreeNURSING SHIFT REPORT Date and time: [Date, time of handoff] Unit and bed: [Unit, room, bed] Giving report: [Nurse name, credentials] Receiving report: [Nurse name, credentials] Where given: [At the bedside, or at the station with a bedside check after] PATIENT AND ALERTS Patient: [Name, age, pronouns] Identifiers checked: [Two identifiers, matched against the wristband] Admitted: [Date, service, and responsible provider] Code status: [Current order, and where it is documented] Allergies: [Each allergy and the reaction, or no known allergies] Isolation: [Precautions and the reason, or none] I: ILLNESS SEVERITY Severity: [Stable, watcher, or unstable] Reason: [One line on why you rate it this way] Early warning score: [Score and trend, if your unit uses one] P: PATIENT SUMMARY Diagnosis: [Reason for the stay or procedure, and day of stay or post-op day] Relevant history: [Conditions that change care this shift] Events this shift: [What changed, with times, who you told, and the response] SYSTEMS Neuro: [Level of consciousness, orientation, and baseline] Cardiovascular: [Heart rate and rhythm, telemetry, BP, edema] Respiratory: [Rate, SpO2, oxygen device and flow, breath sounds, CPAP] GI and nutrition: [Diet or NPO and since when, nausea, last bowel movement, glucose] GU: [Voiding or catheter, output, last void] Skin and wounds: [Incisions, dressings, pressure areas] Pain: [Score and scale, last dose, and reassessment] Mobility: [Activity, aids, and assistance needed] Last vital signs: [Time, temperature, HR, BP, RR, SpO2 and oxygen] LINES, MEDICATIONS, AND LABS Lines and drains: [Each device: type, site, date placed, what is infusing, output] Medications due: [Drug, dose, time, and hold parameters] Given as needed: [Drug, time, and the effect] Held or changed: [What, why, and who decided] Results this shift: [New or abnormal results, and who was told] Pending: [Test, time sent, and who follows it up] Scheduled: [Procedures or imaging, with NPO or prep needed] SAFETY AND FAMILY Safety risks: [Falls, pressure injury, delirium, aspiration, bleeding, or self-harm, and the precautions in place] Restraints or sitter: [Type and next review, or none] Family: [Contact person, what they know, and who may receive information] Patient's goal: [In the patient's words] Discharge plan: [Expected date, ride, and teaching still to do] A: ACTION LIST To do: [Task, time due, and owner] Not done this shift: [What, and why] S: SITUATION AWARENESS AND CONTINGENCY Watch for: [What could go wrong this shift] If it happens: [First step, and who to call] S: SYNTHESIS BY RECEIVER Read-back: [Receiving nurse's summary of severity, tasks, and contingencies] Questions: [What the receiver asked, and the answers] Bedside check: [Patient, lines, pumps, and monitor checked together] Accepted by: [Receiving nurse, time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Cardiac telemetry unit, night nurse to day nurse, at the bedside, 07:00
Bed 14, 68-year-old man. Name and date of birth checked against his wristband with him at the bedside. Admitted yesterday at 16:00 to the hospitalist service with chest pressure on exertion. Full code, as ordered on admission. Allergy: sulfa antibiotics, hives. No isolation. He asked to hear report and joined in.
Watcher. New atrial fibrillation with a rapid ventricular response at 02:50. Rate now controlled, but only 1 hour after his first oral dose of metoprolol.
Chest pain workup, day 2. Two troponins on admission negative; admission ECG sinus rhythm with no acute changes. Exercise stress test booked for 10:00 today. History: hypertension, type 2 diabetes, high cholesterol, and sleep apnea on CPAP; no known rhythm problems. Overnight: telemetry alarm at 02:50 for an irregular narrow-complex rhythm at 130 to 150. He woke with palpitations and mild shortness of breath; no chest pain. BP 132/84, SpO2 95% on room air. 12-lead ECG at 02:55: atrial fibrillation, rate 138. Called the hospitalist with SBAR at 02:58; seen at the bedside at 03:15. Metoprolol 5 mg IV at 03:20, repeated at 03:40; rate 105 to 115. Metoprolol tartrate 25 mg by mouth at 06:00; rate 88 to 102 since 06:15. Still in atrial fibrillation on the 06:30 strip.
Neuro: alert, oriented, calm. Cardiovascular: irregular rhythm, HR 88 to 102 on telemetry; no edema; no chest pain all night. Respiratory: lungs clear; CPAP on from 04:00 to 06:30. GI: NPO since midnight for the stress test, sips with pills; glucose 7.8 mmol/L (140 mg/dL) at 06:00; metformin held while NPO. GU: voiding into a urinal, 650 mL overnight. Skin: intact. Pain: 0/10 all night. Mobility: independent at home; up to the bathroom once with 1 assist at 05:30, no dizziness. Last vital signs 06:30: T 36.9 °C (98.4 °F), HR 96 and irregular, BP 124/78, RR 18, SpO2 96% on room air.
Lines: 20 gauge IV, left forearm, placed on admission; saline lock, flushes well. Telemetry leads changed at 04:00. Given overnight: potassium chloride 40 mEq (40 mmol) by mouth at 04:00, and magnesium sulfate 2 g IV over 1 hour from 04:20. Due: lisinopril 10 mg at 09:00; metoprolol tartrate 25 mg by mouth at 12:00, every 6 hours, held for HR under 60 or systolic BP under 100 with a call to the hospitalist. Labs drawn at 03:20: potassium 3.4 mmol/L, magnesium 0.72 mmol/L (1.75 mg/dL), troponin unchanged from admission. Pending: TSH, sent 03:20. Repeat potassium and magnesium ordered for 09:00. No anticoagulant started overnight.
Falls: asked to call before getting up until the rate settles; bed low, call bell and urinal in reach. Telemetry stays on for walks. No restraints or sitter. Family: his wife is his contact and may receive information. He asked us not to wake her overnight. She usually calls at 08:00, and he wants the team to explain the rhythm change to her. His goal: “Find out if my heart is OK and go home tomorrow.”
08:00, day nurse: ask cardiology on rounds whether the stress test goes ahead, changes to another test, or waits, now that metoprolol has been started; keep him NPO until then. 09:00, day nurse: repeat potassium and magnesium; lisinopril. When back: TSH result to the hospitalist. 12:00: metoprolol, with HR and BP checked first. Anticoagulation: hospitalist and cardiology to decide on rounds. Not done overnight: teaching on the stress test, deferred until the plan is clear.
HR over 120 for 10 minutes, systolic BP under 90, chest pain, new shortness of breath, or dizziness: 12-lead ECG and call the hospitalist; call the rapid response team if he looks unwell. Converts to sinus rhythm: 12-lead ECG to capture it, and tell the hospitalist. Stress test cancelled: he can eat, and glucose checks move to before meals.
Day nurse summarized: “Watcher. New AF with RVR since 02:50, rate 88 to 102 on oral metoprolol. NPO until cardiology decides on the stress test. Potassium and magnesium at 09:00, TSH pending, metoprolol at 12:00 with hold parameters. Call for a rate over 120 for 10 minutes, a systolic under 90, or chest pain.” Asked whether he needs heparin now; answer: not ordered, and the decision is on rounds. Monitor, IV site, and call bell checked together. Accepted at 07:14.
Surgical unit, day nurse to evening nurse, at the bedside, 15:00
Bed 6, 46-year-old woman. Name and date of birth checked against her wristband at the bedside. Total thyroidectomy yesterday morning for a large multinodular goiter pressing on her windpipe; general surgery service. Full code. Allergy: latex, hives; latex-free room. No isolation. Report given with her alone, at her request, before her husband arrives.
Stable. Day 1 after surgery, calcium rising, no symptoms. Discharge ordered for this evening.
Post-op day 1 after total thyroidectomy. History: high blood pressure on amlodipine; mild asthma, no inhaler use this year. Today: calcium 2.08 mmol/L (8.3 mg/dL) at 06:00 and 2.12 mmol/L (8.5 mg/dL) at 12:00; no tingling or cramps. Parathyroid hormone yesterday evening was low, so she goes home on calcium. The surgical resident saw her at 13:30 and wrote the discharge order at 13:40: home tonight after supper and teaching.
Neuro: alert, oriented. Neck: incision closed with skin glue, edges together; neck soft and even on both sides, no swelling or spreading bruise. Checked every 4 hours, last at 14:30. Voice: mildly hoarse since surgery, not getting worse; strong cough. Respiratory: no stridor or noisy breathing. GI: soft diet, ate most of lunch, swallows pills whole, no nausea. GU: voiding. Pain: neck soreness 2/10. Mobility: walking the hallway on her own. Last vital signs 14:30: T 36.8 °C (98.2 °F), HR 76 and regular, BP 132/80, RR 16, SpO2 97% on room air.
Lines: 20 gauge IV, right hand, saline lock; take it out before she leaves. No drain. Given today: levothyroxine 100 mcg at 06:00, her first dose; calcium carbonate 1,250 mg at 08:00 and 12:00; amlodipine 5 mg at 08:00; acetaminophen 1,000 mg at 12:00. Due: calcium carbonate 1,250 mg with supper at 17:00. Acetaminophen can be repeated from 18:00 if needed. Prescriptions for levothyroxine and calcium carbonate sent to her pharmacy at 13:45. Labs: no repeat calcium before discharge, per the resident; the requisition for a calcium level in 2 days is in her discharge package. Final pathology goes to her surgical clinic visit in 2 weeks; nothing to follow tonight.
Bleeding: a neck hematoma is the risk to watch, though she is past the first 24 hours. Head of the bed up 30 degrees. Falls: low risk, walking on her own. Family: her husband drives her home and arrives about 17:30; he may receive information. She wants him there for the medication teaching. Her goal: “Sleep in my own bed tonight.”
17:00, evening nurse: calcium carbonate with supper. 17:30, evening nurse: teaching with her husband present. Levothyroxine on waking with water, 30 to 60 minutes before breakfast; calcium with meals, at least 4 hours after levothyroxine; the signs of low calcium; and when to go to the emergency department. Teach-back from both. Before she leaves: neck check, a full set of vital signs, IV out, and the discharge package with the lab requisition and clinic date. By 16:00: check the resident has signed the discharge summary. Done today: incision care and showering teaching, with teach-back.
Neck swelling, a tight feeling in the neck, trouble breathing or swallowing, or new stridor: sit her up and call the rapid response team and the surgical resident at once; this is an airway emergency. Tingling around the lips or in the fingers, or muscle cramps: hold the discharge and call the surgical resident for a calcium level. Voice much weaker, or coughing when she drinks: hold the discharge and call. If her husband can’t come tonight, she stays and goes home in the morning.
Evening nurse summarized: “Stable, home tonight. Calcium with supper at 17:00, teaching at 17:30 with her husband and teach-back, then vital signs, neck check, and the IV out. Swelling or breathing trouble: rapid response. Tingling or cramps: hold the discharge and call.” Asked whether she needs a calcium level before leaving; answer: no, the resident is satisfied with the 12:00 result, and the next one is in 2 days. Neck and IV site checked together. Accepted at 15:09.
Who the patient is, and the facts that must never be wrong: code status, allergies, and isolation. Check them against the wristband and the chart, not memory.
Avoid: Giving code status from memory. Read it from the current order, since it can change during a stay.
The first thing the receiving nurse hears: how sick the patient is, in one word, with a reason. I-PASS uses stable, watcher, and unstable.
Avoid: Calling everyone stable. A watcher label tells the next nurse where to look first.
Why the patient is here, what changed this shift, and a short pass through each system. Lead with the changes.
Avoid: Retelling the whole admission. Give the history that matters today, and spend the time on what changed.
What is running, what is due, and what results are still out, so nothing is missed or doubled at the change of shift.
Avoid: Using report as the medication check. Confirm doses and times on the MAR, and check pump rates against the orders at the bedside.
The risks that need precautions this shift, the people around the patient, and where the stay is heading.
Avoid: Talking through sensitive details in front of visitors. Ask the patient first who may stay for report.
Every task the next shift owns, each with a time and a name.
Avoid: “Follow up labs.” Name the test, the time it is due, and what to do with the result.
What could go wrong and what to do about it, then the receiving nurse’s own summary. Care moves to the next nurse once they have said the plan back and accepted it.
Avoid: Ending with “any questions?” and walking away. Ask the receiver to say the plan back in their own words.
Report at the station alone misses what the bedside shows: a pump at the wrong rate, a wet dressing, an IV site turning red. Finish at the bedside, with the patient joining in if they want to.
Ten minutes on the admission story leaves no time for the to-do list. Give the history that changes care today, then move to what is due.
A result nobody is watching can sit for hours. Say who checks it, when, and who gets told.
If a watcher patient worsens at 10:00, the next nurse should already know the trigger and who to call. Agree on it during report, not after.
Copying yesterday’s report keeps an NPO order, a code status, or a drain that has since changed. Rebuild it each shift from the current orders and your own assessment.
Vero Scribe writes the shift report in your template from your dictation, or from the bedside handoff with the patient’s consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Patient identifiers, code status, allergies, the reason for the stay, events this shift, a short review of each system, lines and drains, medications due, pending results, safety risks, family and discharge plans, a to-do list, and what to do if the patient gets worse. It ends with the receiving nurse’s read-back.
Use the tool your unit has adopted. I-PASS was built for handoffs: it adds illness severity, an action list, contingency plans, and a summary by the receiver. SBAR fits a call about one problem. This template follows I-PASS, and you can still use SBAR to escalate during the shift.
Fill in the template about 30 minutes before the end of your shift, from the current orders and your last assessment. Start with severity and what changed, keep normal systems to a line, and finish with the to-do list and when to call. Then ask the receiving nurse to say the plan back.
Where you can, yes. Both nurses see the patient, lines, and pumps together, and the patient can correct or add to what is said. Ask first who may stay in the room, and give sensitive details somewhere private.
Yes. Copy it, or download it as a Word or text file. No account needed.
System-by-system nursing assessment with pressure injury and fall risk, lines and drains, and escalation.
The shift note: assessment, timed vital signs and interventions, the response, provider calls, teaching, and the plan for the next shift.
Assessment data, nursing diagnosis, SMART outcomes, interventions with rationale, and evaluation, one diagnosis at a time.
Focus charting in four parts: the focus, the data behind it, nursing actions, and the timed patient response.
Problem, Intervention, Evaluation: numbered nursing problems carried from shift to shift, with the assessment on a flow sheet.
A one-page PDF sheet in Letter and A4 for handwriting, with med-surg worked examples and how to handle paper sheets safely.
Notes and handoffs drafted from your dictation, for your review.
Calls and escalations during the shift, with the receiver’s response.
Chart the events you handed over, in your note format.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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