Received report from outgoing RN, labs, orders, medication profile, trends, plans and family dynamics reviewed. Assumed pt care.
Safety checks completed. Alarms set and armed. Emergency access and equipment present and in working order. Code status verified. Drip calculation, compatibility and allergies verified. Pt stable. Visible from nurses stations. Call button in reach. Bed low and locked. Room clear and well light. Will continue monitoring. See assessment section for systems review.
This is a sample ICU beginning shift RN note. It covers the report and safety checks that must be done within the first 15 minutes in a proper nursing world. On safety checks, you may want to add other things as applicable. Example include restraints, blood transfusions, special procedures in progress. You must show and acknowledge that you looked into them and did recommended safety checks from the word get go.