Share Your "Brain" Sheet

I work on a Cardiovascular/Medicine tele floor (40 beds, 24 of which are 5 lead tele). I have 2 report sheets that I use (one that "holds" 4 patients, one that only holds 1 patient). I work 7a-7:30p Fri-Sun, so I need lots of space to write. I also have a clipboard that I lose all the time! I am new to the site, so I can't figure out how to attach the files, if anyone wants them, please let me know!

I work 12hr day/night rotations. I use this brain sheet I created in addition to the one our floor uses which outlines all the body systems.

You will notice small boxes so I can make checks when I complete the items. For example, on the right side where VS, Med, mar, etc... two boxes that need to be checked. Once for AM, once for PM so I know I did them. I used to have a problem of quadruple checking if I documented things. Now I just check the box so I know if I did it, and I don't look again!

I have to tell you I have been a nurse for 20 years and without my brain sheet I am lost. I need it to remember all the things I have to do and all the patients, I cover 12 patients at a time tooo much for my tired brain!

I use SBAR (status, background, assessment, response) as a foundation for my report sheet. It is handwritten so I cannot post it but I love it.

Basically in rows going down I have a line for each system (N,C,R,GI,GU,I,MS,PS,M). "M" is for metabolic which I also use for for comfort issues.
Then in columns going across I have DX, HX, Status, TX, My ROS, Notes re D/C planning, status changes, etc.

I can then easily talk about their diagnosis down the line, I see the hx and how it may affect the big picture, status is the nurses notes to me, tx is what are we doing, my review of systems as I do my own assessments, then notes on changes that need to be made etc. I like seeing the progression as it relates to each system as I run my eye across the paper. It help me think critically.

Plus I always feel prepared to call a doc if I need to.

I have some smaller boxes to the side that are VS, Meds, Labs.

I also do a quick list of ALL the TYPES of meds (just classifications, like beta blkrs, ca ch blkr, lax, etc) the pt is getting and not just the ones I am administering on my shift. I need to see at a glance what is affecting this pt.

I use one whole page for each pt. Most all nurses here do because our pts are complicated and we have a ratio of 3-4. I designed the page though so I can fold it in quarters and the med timeline and space for "to do" is on one quadrant and I can review it quickly as I go through the night.

Here's my report sheet!

I use a binder with dividers and I use one report sheet for each pt. The report sheet goes into the pocket of the divider and then I print out the MAR (we have eMARs), the pt's labs and the previous shifts VS every morning after report.

Works well for me!

Here is my tele unit brain (SBAR). If possible, I have each patient's SBAR followed by their eMAR. Not all facilities have the eMAR, so then I have another crazy brain med tracker worksheet I made to keep me on target.

Then...
I do a little origami folding magic thing that gives me the appearance of being more organized than I am. I don't really believe it keeps me more organized, but I feel calmer when I see that at least my papers appear organized....

If there is a printable copy of the facility's quick reference guide for things JAHCO or State might question me on, (who is your safety officer, where is your blah blah...) I print that on a colored sheet of paper and us it as a cover/top sheet...the different color makes my brain easier to spot from accross the room, the cover sheet has answers I may need some day, and it adds a layer of HIPPA protection.

As a traveler, I feel like I have this one thing that is a constant. Ahhhhhh.

To: SunInMyHeart - I would love to see a sample of the worksheet you describe. It sounds exactly like what I need to be able to see the "whole picture", which I have trouble doing. Is there anyway you can upload a sample? Thanks!

Thank you everyone, these will make my life easier and help put my mind at ease

What kind of floor /unit will you be working on and how many patients do you get a shift? Min? Max? Do you have residents or NPs or PAs that work as teams at your hospital? If you can answer these questions for me and maybe a few others I can put a couple different styes togehter for you....... I have done this a couple of times for nurses on units I would float to when they would see my worksheet and want to use it--but I tweaked it to fit their unit more specifially.
So let me know if you want some help.....send me a private message if you like that way I can ask any other info I may need........

I work in the ICU and occasionally float to Tele & the CVU. I made my sheets and they have become popular among some of the staff I work with as well. Honestly, I would be lost without them. The items with check boxes like "PP, KD, IVMD and PAIN" are just charting reminders for myself. Those are the things we must chart on every patient. It has an area for most things I would need a quick reference to if asked by a doc. I made it with Excel, but posted as an image here. Enjoy.