Brain Sheet

I don't know of any ED nurses who use brain sheets. I designed my own brain sheet when I was a floor nurse. I'm not sure how useful a typical med-surg brain sheet would be for an obs unit. I'd just design my own.

I usually just job myself notes and cross out as I do things. Patient turnover is so great that a standard brain sheet would be more of a hindrance than a help.

Only times I write notes are for holds & psych stories.

See attatched for a copy of my report sheet I use in the ICU... I'm not sure if this is what you were asking for when you referred to your "brain sheet"?

This is my brain sheet:

In the E.D. brain sheets can slow you down. Usually if you do keep notes, it's like this:

(Room) 2- VS, IV, BP up.

3- Labs, urine

4- Recheck temp, meds due

In other words, if I'm going to use a brain sheet, it's more to remind me of what that patient needs at that time. 99% of what I do is computerized and easy to get to from anywhere in the E.D. so no detailed sheet is needed.

The closest thing to a brain sheet I used in the ED was the back of the medic slip, where I would take notes of the EMT's report, add my own observations, and then transcribe it to the chart in an organized format.

In an observation unit, I'm guessing you'll need to include much of the same basic information that you would use on a medical floor, only tailored for the obs unit. Basically on an obs unit, you're doing a lot of ruling out and waiting for conditions to declare themselves, so you're watching vital signs trends, labs, diagnostics, etc. so the physician can determine if the patient needs hospitalization or is safe to return home.