Why ICU Report Sheets Matter
In the high-acuity environment of the ICU, nurses are the chief healthcare providers, spending the majority of their time collecting, integrating, and utilizing patient data. ICU patients are typically unable to participate in their own care and are extremely vulnerable to medical errors. A well-designed report sheet is your lifeline for accurate documentation and safe patient handoffs.
Communication Failures in Healthcare
An estimated 67% of harmful medical errors are related to handoff communication failures. Studies show that ICU units implementing structured handoff protocols reduced missed interventions by 30%.
The AHRQ's Strategy 3: Nurse Bedside Shift Report emphasizes involving patients and families to ensure safe care transitions.
This guide provides comprehensive ICU report sheet templates, SBAR handoff frameworks, and documentation best practices specifically designed for critical care environments in 2026.
SBAR Framework for ICU Handoffs
The SBAR (Situation, Background, Assessment, Recommendation) framework is the gold standard for structured communication in healthcare. Studies show that using SBAR during patient care transfers leads to increased effectiveness and improved outcomes for over 73% of patients.
S - Situation
Current status at a glance
- • Patient identification: Name, room number, age, gender
- • Admission diagnosis: Why they're here
- • Code status: Full code, DNR/DNI, comfort care
- • Current concern: What's happening right now
- • Attending physician: Who to call for orders
B - Background
Relevant history and context
- • Medical history: Comorbidities, past surgeries
- • Recent procedures: Surgeries, interventions, imaging
- • Allergies: Medications, latex, contrast
- • Isolation status: Contact, droplet, airborne
- • Hospital course: Key events since admission
A - Assessment
Current clinical status (system-by-system)
- • Vital signs & trends: HR, BP, RR, SpO2, Temp
- • Neurological: GCS, RASS, CAM-ICU, pupils
- • Respiratory: Vent settings, ABG, secretions
- • Cardiovascular: Rhythm, drips, hemodynamics
- • GI/GU: I&Os, feeding, bowel function
- • Skin/Lines: Wounds, tubes, IV sites, restraints
- • Labs: Recent results, pending studies
R - Recommendation
What needs to happen next
- • Pending tests/procedures: CT, echo, labs due
- • Anticipated issues: Weaning, extubation, transfer
- • Goals for shift: What to accomplish
- • Family updates: Who to call, concerns discussed
- • Special considerations: VTE prophylaxis, stress ulcer, etc.
Comprehensive ICU Report Sheet Template
This template is designed for adult ICU patients and includes all the critical elements needed for safe, comprehensive shift handoffs. Customize based on your unit's specific needs.
Patient Header
Name
_______________
Room / Bed
_______________
Age / Sex
_____ / _____
Code Status
_______________
Admission Date
_______________
Diagnosis
_______________
Allergies
_______________
Attending / Team
_______________
Isolation
_______________
Vital Signs & Ventilator
Hourly Vitals
| Time | HR | BP | RR | SpO2 | Temp |
|---|---|---|---|---|---|
| ____ | ____ | ____ | ____ | ____ | ____ |
| ____ | ____ | ____ | ____ | ____ | ____ |
| ____ | ____ | ____ | ____ | ____ | ____ |
| ____ | ____ | ____ | ____ | ____ | ____ |
| ____ | ____ | ____ | ____ | ____ | ____ |
| ____ | ____ | ____ | ____ | ____ | ____ |
Ventilator Settings
Vasoactive Drips & IV Access
Continuous Infusions
Vascular Access
Neurological & Sedation Assessment
RASS Scale
| +4 Combative |
| +3 Very agitated |
| +2 Agitated |
| +1 Restless |
| 0 Alert & calm (target) |
| -1 Drowsy (target) |
| -2 Light sedation |
| -3 Moderate sedation |
| -4 Deep sedation |
| -5 Unarousable |
Current RASS: _____
Target RASS: _____
Neuro Check
System Assessment
Cardiac
- Rhythm: ___________
- Edema: ___________
- Pulses: ___________
- MAP target: _______
Respiratory
- Breath sounds: _____
- Secretions: ________
- Last ABG: _________
- Chest tube: _______
GI/GU
- Diet/TF: __________
- Bowel: ___________
- Foley: ____________
- UOP/hr: __________
Skin/Wounds
- Skin integrity: _______________
- Pressure injury: _____________
- Surgical site: _______________
- Braden score: _______________
Tubes/Drains
- NGT/OGT: _________________
- Chest tube: _______________
- JP/Hemovac: ______________
- Other: ___________________
Labs & Pending
Critical Labs
Pending / To Do
- _______________________
- _______________________
- _______________________
- _______________________
ICU Documentation Frequency
Understanding when and how often to document is critical for patient safety and regulatory compliance. Here's the recommended documentation schedule for ICU patients:
| Assessment | Frequency | Notes |
|---|---|---|
| Vital Signs | Q1H (hourly) | More frequent if unstable |
| Complete Head-to-Toe Assessment | Q4H | Full system assessment |
| Focused Assessment | Q2H | Target patient's main issues |
| RASS Score | Q2H minimum | Required for ventilated patients |
| CAM-ICU (Delirium) | Q8-12H | Each shift minimum |
| Intake & Output | Q1H totals | Shift totals at handoff |
| Ventilator Settings Check | Q1-2H | Verify with orders |
| Line/Tube Assessment | Q shift + PRN | Document at handoff |
| Skin Assessment | Q shift | With repositioning |
Bedside Shift Report Checklist
Bedside shift report has been shown to decrease patient falls by 24% and improve both patient and nurse satisfaction. Use this checklist to ensure a thorough handoff:
Before Entering the Room
- Review patient chart in EHR
- Check recent labs and imaging
- Review medication list
- Note pending orders/consults
- Verify code status
- Prioritize unstable patients first
At the Bedside
- Introduce oncoming nurse to patient/family
- Verify patient ID band
- Conduct focused assessment together
- Inspect all wounds/dressings
- Verify IV sites and tubing labels
- Trace all tubing from pump to patient
- Verify ventilator settings match orders
- Check ETT placement/securement
- Safety scan of room environment
- Ask patient/family if they have questions
Communication Confirmation
- Oncoming nurse verbalizes understanding (read-back)
- Address any questions or concerns
- Document handoff in EHR
Frequently Asked Questions
What is an ICU report sheet?
An ICU report sheet (also called a brain sheet) is a structured documentation tool that critical care nurses use to track patient information throughout their shift. It includes sections for vital signs, ventilator settings, medications, labs, hemodynamic monitoring, and nursing assessments, enabling accurate handoff communication between shifts.
What is the SBAR format for ICU handoff?
SBAR stands for Situation, Background, Assessment, and Recommendation. In ICU settings, Situation covers the patient's current status; Background includes medical history, recent procedures, and code status; Assessment covers vital signs, ventilator settings, drips, and system-by-system findings; Recommendation outlines pending tests, anticipated changes, and goals of care.
How often should ICU nurses document assessments?
ICU nurses typically perform a complete head-to-toe assessment every 4 hours (Q4H) and a focused assessment every 2 hours (Q2H). Hemodynamic parameters and ventilator settings may require hourly documentation. RASS scores should be documented at least every 2 hours for mechanically ventilated patients.
What is the RASS scale and why is it important?
The Richmond Agitation-Sedation Scale (RASS) is a 10-point scale ranging from -5 (unarousable) to +4 (combative) used to assess sedation levels in ICU patients. It's essential for titrating sedation medications, targeting lighter sedation levels (usually RASS 0 to -1) to reduce delirium and ventilator days.
What should be included in an ICU bedside shift report?
An effective ICU bedside shift report includes: patient identification and code status, current vital signs and trends, ventilator settings and respiratory status, vasoactive drips and titration parameters, recent labs and pending tests, skin assessment and line/tube verification, goals for the shift, and any family concerns or code status discussions.
How can ICU report sheets improve patient safety?
Structured ICU report sheets reduce communication failures (responsible for 67% of medical errors), ensure no critical information is missed during handoffs, provide visual reference for medication drips and alarm parameters, and facilitate faster escalation of deteriorating patients. Studies show ICUs using structured handoffs reduce missed interventions by up to 30%.
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