Traveling Nurse Care Shift Report Form
Please complete this form at the end of each shift to summarize your assignment, key activities, and any notable events. Do not include sensitive health or personal information.
Nurse Name
*
First Name
Last Name
Nurse ID or Staff Number
*
Facility / Location
*
Unit / Department
*
Please Select
Medical-Surgical
ICU
Emergency
Labor & Delivery
Pediatrics
Other
Shift Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Shift End Time
*
Hour Minutes
AM
PM
AM/PM Option
Patient Load Summary (number of patients, acuity, etc.)
*
Key Tasks Completed
*
Notable Issues / Escalations / Handoff Notes / Follow-up Actions
Submit Shift Report
Should be Empty: