Clinical templates
The sheets students actually pull out at the start of a shift. Hit print, fill by hand, hand to your preceptor at the end of the day.
How to use this page
Each template below is print-ready. Open the one you want, press Ctrl+P (Cmd+P on Mac), and the nav, footer, and these instructions drop out. You'll get a clean blank you can fill with a pen during clinicals or your first shift.
Voice on these is direct, not perfect. The point is something you'd actually use, not a polished form that lives in a binder.
Template 1
The half-page-per-patient sheet that holds you together through a 12-hour shift. Patient summary, vitals due, meds due, labs pending, assessments to do, follow-ups by shift block. Use one per patient.
Patient (initials)
Room
Age / Sex
Admit date
Code status
Allergies
Admitting diagnosis + brief story
History / comorbidities
IV access (size, location, fluid)
Assessment by system
Neuro
Cardiac
Resp (O2, sats, sounds)
GI / GU (BMs, urine output)
Skin / wounds / lines
Pain (rating, last med, plan)
Vitals due (times)
Meds due (times)
Labs pending / drawn
0700-1100
1100-1500
1500-1900
1900-end
Concerns / watch for
Goals / plan for shift
To do before report off
Press Ctrl+P (Cmd+P on Mac) to print one blank per patient. Fold in half lengthwise so the systems-assessment grid lives on one side and the task blocks live on the other.
Template 2
The standard handoff structure. Situation, Background, Assessment, Recommendation. Use it before you call the provider, before you report off, and any time you need to be clear about what's changing and what you want done.
Patient (initials)
Room
Date / time
Situation
One line: who is this and what is happening right now?
Background
Why are they admitted, relevant history, last vitals / labs you'd want a fresh ear to know.
Assessment
What do you think is going on? Use clinical language; this is the nurse's read.
Recommendation
What do you want done? Med order, transfer to higher acuity, a quick bedside visit, lab repeat.
Called by (name, role)
Spoke to (name, role)
Orders received
Readback confirmed?
Print blanks before your shift and clip a few to your brain sheet. The Recommendation line is the one you'll keep rewriting in school; it gets shorter and more direct the more shifts you work.
Template 3
The end-of-shift summary you read off when the next nurse takes your patients. Faster than your brain sheet, structured so you don't forget the things that get people hurt: lines, allergies, code status, recent changes.
Patient
Room
Code status
Allergies
Why they're here (one line)
Active issues
Lines, drips, tubes, drains
Last vitals + any trends
Pain (last med, plan)
Pending labs / studies / consults
Anticipated needs for next shift
Family / psychosocial notes
To do (specific tasks before you leave)
Hand this to the oncoming nurse at the end of report. The anticipated-needs block is the one most schools skip; it's the one that makes you sound like a nurse, not a student.