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Nursing · Free printables

Nurse report sheet and SBAR builder

Build a printable report sheet (brain sheet) for your unit, practice an SBAR handoff from a script, and keep a Glasgow Coma Scale study card and a head-to-toe checklist on one page. For study and shift organization: nothing about a patient is typed in, saved or sent.

  • Prints only the sheet
  • Nothing typed in or saved
  • For study and shift organization
  • No sign-up needed

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Part 1 · Report sheet builder

Build a report sheet for your unit

Pick a layout, how many patients share a page, and the boxes you want. The preview updates as you choose, and printing puts only the blank sheet on paper.

Unit layout
Patients per page
Shift for the hourly grid
Boxes to include

8 of 10 selected

Printing uses your browser’s print dialog: choose letter or A4, portrait, default margins. Only the sheet prints, and your browser’s own Print command prints it too.

Preview

Blank boxes and labels only. Nothing is typed in or saved.

Two full-height columns on one page; the notes box fills what is left.

Med-surg · Day 0700–1900 · Date ________

Patient 1 of 2

SBAR header

Room
Initials
Age
Code status
Allergies
Admit date
Diagnosis
History
Team
Isolation
Diet
Activity

Head-to-toe systems

NeuroLOC · orientation · pupils · strength
Cardiacrhythm · pulses · edema · cap refill
Resprate · sounds · O2 · cough
GIdiet · bowel sounds · last BM · nausea
GUvoid · catheter · output
Skincolor · wounds · pressure points
Mobilitygait · device · fall risk · activity
Painscore · site · PRN last given

Lines, drains and airway

IV site · gauge · date
IV site · gauge · date
Drains · tubes
Airway · O2 device

Labs

CBC
BMP / CMP
Coags
Glucose
Cultures
Other
Pending

Meds and times

Time · med · dose
PRN · last given

Intake and output

Intake
Output
Last BM
Voids

Hourly to-do

07
08
09
10
11
12
13
14
15
16
17
18

Notes and to-do

Discharge plan · calls · questions

Med-surg · Day 0700–1900 · Date ________

Patient 2 of 2

SBAR header

Room
Initials
Age
Code status
Allergies
Admit date
Diagnosis
History
Team
Isolation
Diet
Activity

Head-to-toe systems

NeuroLOC · orientation · pupils · strength
Cardiacrhythm · pulses · edema · cap refill
Resprate · sounds · O2 · cough
GIdiet · bowel sounds · last BM · nausea
GUvoid · catheter · output
Skincolor · wounds · pressure points
Mobilitygait · device · fall risk · activity
Painscore · site · PRN last given

Lines, drains and airway

IV site · gauge · date
IV site · gauge · date
Drains · tubes
Airway · O2 device

Labs

CBC
BMP / CMP
Coags
Glucose
Cultures
Other
Pending

Meds and times

Time · med · dose
PRN · last given

Intake and output

Intake
Output
Last BM
Voids

Hourly to-do

07
08
09
10
11
12
13
14
15
16
17
18

Notes and to-do

Discharge plan · calls · questions

Part 2 · SBAR builder

Practice an SBAR handoff

Choose the kind of call. You get a script with a [bracket] for every item to fill in on paper or say out loud, and one worked example to hear the rhythm of it.

Practice only. Never type real patient details anywhere online, including here. For a real handoff or escalation, follow your facility’s policy and its own forms.

S

Situation

A concise statement of the problem.

B

Background

Brief information that bears on the situation.

A

Assessment

What you found and what you think is going on.

R

Recommendation

What you want: the action you are asking for.

Situation

Script: Change in condition

  1. S Situation

    • This is [your name], [role] on [unit], calling about [patient initials and room].
    • I am calling because [what changed] started at [time] and I am concerned.

  2. B Background

    • [Age]-year-old admitted [date] with [reason for admission]. Code status: [status].
    • Relevant history: [conditions]. Allergies: [allergies].
    • Vitals now: [T, HR, BP, RR, SpO2, pain]. Earlier: [previous set, time].
    • Recent changes: [new meds, procedures, results].

  3. A Assessment

    • I think the problem is [your read of the situation] / I am not sure what the problem is, but the patient is getting worse.
    • What I have seen: [findings that support that].

  4. R Recommendation

    • I would like you to [come and see the patient / give an order for] within [time frame].
    • Should I [action you are asking about] in the meantime?
    • When should I call you back, and for what change?

Worked example · fictional

Fictional example: a change in condition on a telemetry unit

Made up to show the shape of a call. There is no such patient, unit or nurse.

S Situation
This is Dana, the RN in room 12 on telemetry, calling about Mr. R. His breathing rate has gone from 18 to 28 over the last hour and he tells me he is short of breath.
B Background
He is a 67-year-old admitted two days ago after a hip repair. Code status is full code. He has a history of heart failure. His oxygen saturation is 90% on 2 liters by nasal cannula; it was 96% at the last set. I hear new crackles at both lung bases. His intake has been about 1.5 liters more than his output since midnight.
A Assessment
I think he may be fluid overloaded, but I am not sure. He is working harder to breathe and it is getting worse, not better.
R Recommendation
I would like you to come and see him now. Is there anything you want me to get ready before you arrive? If his saturation drops below 90% or his breathing rate climbs, I will call you back right away.

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Part 3 · Glasgow Coma Scale study card

Glasgow Coma Scale, on one card

The three components with the current structured-approach descriptors, how a rating is written and reported, what NT means, and six fictional scenarios to practise on.

For study only, not for patient care. This card and its scenarios are for learning the scale; they never rate a real person.

EEye opening
ScoreResponseCriterion
4SpontaneousOpen before stimulus
3To soundAfter spoken or shouted request
2To pressureAfter finger tip stimulus
1NoneNo opening at any time, no interfering factor
NTNot testableClosed by local factor
VVerbal response
ScoreResponseCriterion
5OrientatedCorrectly gives name, place and date
4ConfusedNot orientated but communicating coherently
3WordsIntelligible single words
2SoundsOnly moans or groans
1NoneNo audible response, no interfering factor
NTNot testableFactor interfering with communication
MBest motor response
ScoreResponseCriterion
6Obeys commandsObeys a 2-part request
5LocalisingBrings hand above clavicle to stimulus on head or neck
4Normal flexionBends arm at elbow rapidly, but features not predominantly abnormal
3Abnormal flexionBends arm at elbow, features clearly predominantly abnormal
2ExtensionExtends arm at elbow
1NoneNo movement in arms or legs, no interfering factor
NTNot testableParalysed or other limiting factor

The four steps

  1. 1.Check. For factors that interfere with communication, the ability to respond, and other injuries.
  2. 2.Observe. Eye opening, the content of speech, and movements of the right and left sides.
  3. 3.Stimulate. Sound: a spoken or shouted request. Physical: pressure on the finger tip, the trapezius or the supraorbital notch.
  4. 4.Rate. Assign the highest response observed.

How it is reported

  • The total runs from 3 (the lowest possible) to 15 (the highest). It is the sum of the three component values.
  • Write the components as a short hand, E then V then M, e.g. E2V4M6, and add them for the total: E2V4M6 = 12.
  • Describe all three responses, not the total alone: a total of 8 could be E2V2M4 or E1V1M6, two very different pictures.
  • A component that cannot be tested is recorded as NT (not testable), never as 1, and no total is reported while any component is NT. With a breathing tube in place, the verbal response is NT; the eye and motor responses are still assessed and recorded.

Wording of the structured approach

  • Eye opening "to pressure" replaced the older "to pain".
  • The verbal labels "inappropriate words" and "incomprehensible sounds" became simply "words" and "sounds".
  • Physical stimulus starts at the finger tip; the trapezius and the supraorbital notch follow in a graded sequence. Rubbing the knuckles on the sternum is strongly discouraged.

Head-injury bands, as commonly cited

BandTotal score
Mild13 to 15
Moderate9 to 12
Severe3 to 8

A summary of the total only, and sources draw the edges slightly differently: the glasgowcomascale.org FAQ words severe as a sum under 8. The component ratings carry the detail, and no total is reported while any component is NT.

Practice scenarios

Scenario 1 of 6 · 0 of 18 ratings right so far

Fictional, written to the criteria above. Rate each component, then check.

Eyes are open as you walk into the room. Asked, the person gives their name, the hospital and today’s date correctly, and lifts the left arm and then touches the nose when asked to do both.

Part 4 · Head-to-toe checklist and SOAP template

Head-to-toe checklist and a SOAP template

Tick through the systems as you practise, then print the blank checklist or the SOAP template on its own.

A study checklist of what each system assessment covers, written after the Open RN Nursing Skills 2e checklists. It is not a procedure: with a patient, follow your facility’s policy and your instructor.

0 of 55 items ticked

Before every assessment

  • Hand hygiene; check the room for transmission-based precautions
  • Introduce yourself, your role, the purpose of the visit and how long it will take
  • Confirm identity with two identifiers, such as name and date of birth
  • Explain what you will do and ask for questions; keep privacy and dignity
  • Assess ABCs (airway, breathing, circulation) before the focused assessment

After

  • Comfortable position; ask for questions; thank the person
  • Call light within reach · bed low and locked · side rails secured · table within reach · room clear of fall risks
  • Hand hygiene; document the findings and report concerns according to agency policy
General survey
Neurological
Head and neck
Eyes and ears
Cardiovascular
Respiratory
Abdominal (GI and GU)
Musculoskeletal
Integumentary (skin, hair, nails)

SOAP note template

Four parts, one line each on what goes where. Print it blank and fill it in on paper while you study.

S

Subjective

What the person tells you, in their words.

concern · symptoms · how long · what helps or worsens

O

Objective

What you measure and observe.

vital signs · exam findings · results

A

Assessment

What S and O add up to: your reading of the problem or the progress.

problem · change since last note

P

Plan

What happens next, and who was told.

orders · teaching · follow-up · who was notified

Free bonus

Unlock 4 more sheets and an SBAR pocket card

  • Four sheets ready to print: med-surg 4-patient, ICU 2-patient, telemetry night and ICU 1-patient layouts
  • An SBAR pocket card and a Glasgow Coma Scale badge card, sized for a badge holder
  • A new-grad shift checklist, from before the shift to the last hour

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Bonus

Four ready-to-print sheets, two badge cards and a new-grad checklist

Locked until you enter your email above

  • Med-surg, 4 patients on one page. Four compact blocks with a header, systems, labs, meds, a 12-hour day grid and notes.
  • ICU, 2 patients. Vitals rows, drips and vent lines, lines and drains, labs, hourly grid.
  • Telemetry, 2 patients, night shift. A 1900 to 0700 grid with a rhythm line and vitals rows per patient.
  • ICU, 1 patient, night shift. A full page for one patient: every box, with room to write.
  • SBAR pocket card. The four parts with the prompts to run through, and what to have in front of you before a call, sized for a badge holder.
  • Glasgow Coma Scale badge card. Every score and response name on one badge-size card, with the NT and reporting rules.
  • New-grad shift checklist. Before the shift, handoff, the first hour, through the shift and the last hour.
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Sources

Where the facts come from

Everything here is written in our own words from these public sources. Check anything important against them and your program.

Questions

Common questions

A report sheet, or brain sheet, is the one page a nurse keeps on a clipboard for each patient during a shift: a header with the basics, a line per body system, lines and drains, labs, meds and their times, an hourly to-do grid and notes. It is taken in report, carried all shift and used to give report at the end. Part 1 builds a blank one for your unit.

Situation, Background, Assessment, Recommendation: a way to frame a call or a handoff so the problem comes first, the relevant background next, then what you found and think, then what you are asking for. Part 2 gives you a script for each kind of call and one fictional worked example.

The total runs from 3 to 15: eye opening 1 to 4, verbal response 1 to 5 and best motor response 1 to 6, added together. The three responses are always described, not just the sum, for example E4V5M6 = 15, and a component that cannot be tested is written NT, never 1, with no total reported. Part 3 has the full card and practice scenarios.

No. Everything on this page is for study and for organizing your own shift. It does not assess, rate or make decisions about a real person. With a patient, follow your facility’s policy, its forms and your instructor.

Nothing is typed in. The report sheet prints blank, the SBAR scripts use brackets you fill in on paper, and the checklist ticks and practice ratings live only on your screen until you leave the page. The only thing you can send from this page is the email address for the bonus, if you choose to enter it.