Bonus Resource #2

New Nurse Brain Sheet

Guide for New Nurses on a Busy Unit – Second Edition

Name: ___________________________

Date: ___________________________

Unit: ___________________________

Shift: ☐ Days ☐ Nights

Shift Priorities

Today's Goals

High-Risk Patients

Patient 1

Room: ____________

Age: _______

Diagnosis

Code Status

☐ Full Code

☐ DNR

☐ DNI

Allergies

Isolation

☐ None

☐ Contact

☐ Droplet

☐ Airborne

☐ Other ___________________

Assessment

Neuro

Respiratory

Cardiac

GI/GU

Skin/Wounds

Pain

Mobility/Fall Risk

IV Access

☐ Peripheral

☐ PICC

☐ Central Line

Location _______________________

Oxygen

☐ Room Air

☐ Nasal Cannula

☐ Mask

Flow Rate ___________

Labs to Follow

Critical Labs

Medications Due

0600 _______________________

0900 _______________________

1200 _______________________

1400 _______________________

1700 _______________________

2100 _______________________

PRN ________________________

Treatments

☐ Dressing Change

☐ Blood Sugar

☐ Foley Care

☐ Wound Care

☐ IV Antibiotics

☐ Incentive Spirometer

☐ Other

Orders

☐ PT

☐ OT

☐ Respiratory Therapy

☐ Imaging

☐ Labs

☐ Dialysis

☐ Procedure

Notes

To-Do List

☐ Admission

☐ Discharge

☐ Education

☐ Call Provider

☐ Update Family

☐ Care Plan

☐ Charting

Notes

End of Shift

Pending

Report Notes

Repeat for Patients 2–6

Use the same layout for each additional patient.

Shift Task Checklist

Beginning of Shift

☐ Receive report

☐ Safety round

☐ Review orders

☐ Review labs

☐ Check MAR

☐ Introduce yourself

☐ Whiteboard updated

☐ Initial assessment

☐ Prioritize patients

Throughout Shift

☐ Morning medications

☐ Reassessments

☐ Charting completed

☐ Treatments completed

☐ Labs reviewed

☐ Provider notified of changes

☐ Family updated

☐ Pain reassessed

☐ Hourly rounding

☐ Toileting

☐ Repositioning

☐ Intake & Output

End of Shift

☐ Final assessments

☐ Documentation complete

☐ Orders addressed

☐ IV fluids checked

☐ Controlled substances counted

☐ Bedside report completed

☐ Patient safety verified

SBAR Notes

Situation

Background

Assessment

Recommendation

Andrea's Clinical Pearls

✓ See every patient as soon as possible after report—even a quick visual assessment can help you identify who needs immediate attention.

✓ Complete your head-to-toe assessment with your first medication pass whenever appropriate to save time and establish a baseline.

✓ Chart as you go whenever possible. Waiting until the end of the shift increases the chance of forgetting important details.

✓ Before calling a provider, gather the patient's latest vital signs, recent laboratory results, intake and output, current medications, allergies, and your assessment findings. Anticipate what orders they may request.

✓ Before leaving a patient's room, ask yourself: "Is there anything else I can do before I leave?" Clustering care reduces interruptions and improves efficiency.

✓ Never leave a patient's room without ensuring the bed is in the lowest position, the call light is within reach, and any necessary safety precautions are in place.

Copyright © 2026 Andrea Patterson, RN, MSN
AGA Clinical Development & Workforce Training, LLC