Help getting organized?

Nurses New Nurse

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Like many new nurses posting on this board, I'm having trouble organizing the info I get during change of shift and during my shift and also tasks I need to complete. As a result, I end up spending unnecessary time looking for information I probably have written somewhere and also quadruple checking that I've done a task already. And I don't feel like I give report in the most coherent fashion because I'm scrambling to find info in pages of notes. My goal is to get all my info for my 5-7 patients on one double-sided sheet of paper.

Some nurses have offered to send their "brains" or "cheat sheets" to those of us who are struggling with this problem. I wonder if it would be possible to find a place to post these documents (I know we can't use attachments on this site) somehow on this site or somewhere else, so that we can have a resource. That way people won't have to keep e-mail these documents. Any ideas?

And in the meantime, if anyone has a brain they could e-mail, that would help a lot! I have been struggling all morning to come up with one on the computer and can't get a hang of the formatting. :rolleyes: Last month I made a checklist of all the forms I need to complete before end of shift on my patients, and it's saved me about thirty minutes work every day.

I'm so thankful for all the help I've gotten from these forums. Whenever I feel overwhelmed about my new career, I turn to the site and am so relieved to find that I'm not alone!

Suz

Specializes in Psych, substance abuse, MR-DD.

I'm still in school but my instructor this semester suggested that we use a 3 ring binder with dividers. I LOVE IT! I bought plastic dividers that have two pockets on each one and I keep each patient in a different section. The first page is like a cheat sheet/report sheet with all the vital info, then I have my MAR and notes and all the paperwork I have to do on them. It has really helped me be organized and I will continue to do it this way after I graduate in MAY!

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Specializes in ICU, telemetry, LTAC.
ashley_michelle said:
I don't really thing that using or not using a clipboard will have anything to do with you 'being in a group.' People do all sorts of different things on the floor that I work on... it's just whatever is best for you. Some use clipboards... some use one sheet of paper.. some use notebooks ( 3 ring binders ) .. just whatever makes you feel more comfortable. Using a 3 ring binder helps if you want to keep certain numbers ( materials, different units, PAR, etc) so you can get to them quick without searching at the front desk for them. Also, you can keep reminders in there.. policy's or things that you keep getting stuck on.

So really, who cares what you use.. as long as it works for YOU. I keep all of my kardex on hand.. and have highlighted sections. (meds, new orders, diets, activity, MIVF, etc) and then I use a cover sheet to make a check list for each patient for the night. .. meds and times, any flushes or boluses, PRN meds, fingersticks,dressing changes.. just the things I HAVE to do that night. It works well enough for me. And as far as reports... we record ours and I just pretty much read my full assessment and add PRN's , mivf and vital sign ranges for the shift.

Another perc for a 1/2'' binder ... you can get a little zip pocket of some sort to put highlighters/pens/scissors/alcohol pads.. etc.. so you're not always scrambling in your pockets for stuff. And of course you can add pictures to the front so everyone gets to see a little of the personal/home life. Everyone likes looking at pictures. ? Just don't worry about what the other nurses are doing.. just as long as you keep organized..

Okay, I've kept your idea in mind and started trying it lately. It works very well! I have a 1 inch binder that I bought with a cover on it so you can slide papers in the outside and still see them; I stick the floor report for the unit in there so I can see it quickly. I keep my report sheets in pockets; have a zip pocket in there for things I need but haven't got room for in my pockets. I put the MAR's in there and the nurse notes. Now I can make a note while watching people breathe in the middle of the night; or write notes while going up and down the hall when it's busy. It works well enough that the last few nights I tried it, I bought myself about a half hour extra time and didn't feel as rushed in the rooms so I could enjoy talking with the patients a bit more.

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I will graduate in 3 weeks. My advice to the thread is what I did last semester in clinicals. We had to take 4-5 pts. each day on med-surge and I would have never accomplished this without my NOTEBOOK. All of the nurses on this floor did this. I had a 1in. binder, with a divider with pockets for each pt. I put my "brains" on the very front which had times for meds/procedures for each pt., with all of their vital info. so I could see what I needed to do each hour. THen I put the clients MAR and nurses notes or any paperwork in their divider. Also, each pt. had a three-ring ziplock bag next to the divider and when I pull meds., I place all of the meds in the bag for that pt. That way when you go to give meds, you have all of the meds with you, in their own bag. THis is what I plan to do when I graduate, I hope it might help someone.

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Specializes in ER, Med-Surg, EMS.

I know just how you feel! I'm a new LPN grad and graduate from RN school in 4 wks! YEA!

I know how hard it IS to get organized at the start of my shift - esp when I have 5-6 patients!

This forum ROCKS for ideas, forms, advice! TRY some new things and you'll be surprised where it takes you!

Good luck!

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Specializes in Medsurg.

I've learned to not carry around a clipboard during my preceptor days. I noticed that I was always losing it, and leaving it in weird, sometimes unsanitary places. Also, it was always in the way and so noisy. I learned to keep all my notes/info on ONE sheet of paper, folded into my pocket. It just made everything easier. Also another reason is because I'm totally unorganized...and would just end up with a pile of paper at the end of shift. I get frustrated shuffling through paper.

Just keep to whatever is easier and comfortable for you.

 

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Specializes in ER, Med-Surg, EMS.

I work 3-11 pm shifts. I have tried going in early so I can get all my Kardex info and labs for my patients on my shift - but the Charge Nurse doesn't even MAKE the assignments until like 2:30 or 2:45 pm - which doesn't give me much time to sit and do all that I'd like to do.

Any suggestions?

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Specializes in Rehab, Med Surg, Home Care.

In school our instructors wouldn't allow us to use a clipboard because they didn't want it being carried from room to room and set down on dirty tables, etc.

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Specializes in Cardiac/Med Surg.

WOW!, that sounds well organized, I am looking for that because I start 5/24 in a cardiac stepdown unit and I am starting to get nervous, what should I bring the first night, what do they tell you in orientation (21 and 22) and will I remember how to assess, lung sounds etc....meds,....OMG the list goes on and on, thanks for you information!!

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Specializes in Med Surg - yes, it's a specialty.

I can only tell you what I do. Organization will come with time, as you learn your own little system.

Get everything in one place. I carry a clipboard (yep, and I don't feel silly). I call it my brain and it goes where I go. Even comes in handy like a little tray when I have a lot to carry. My clipboard opens. Inside my first page is a typed up list - stuff I can't remember - like how many mg in a grain. Extension numbers. Doctor numbers. Just a quick reference. Next is an old report sheet from the night before (they don't always tell all in report the next time I come in). Next is a small assortment of stuff I just think I needed but usually don't. Like a couple blank nurses notes for a quick grab or blank paper (sometimes you gotta start jotting fast).

Now as to my report sheet. I ALWAYS write the same stuff in the same places. We don't use a kardex type sheet - it's a computer printout with some note space and some basic pt info and some little blocks. I can "quick glance" if I need to cause DNR is written uniformly in the same spot for my DNR pts. Fall risk is noted with a little f to the left of their name. Tele is a T in a specific spot. Some nurses draw a quick little heart for tele. IV fluids - always in same square. I use the notes space to jot pt stuff if I have to chart later or if I need to be sure I notice something when in room. Such as - NEURO CHECKS Q4HRS. Above each pt is a grey area. I write if they need something there. Like "pain" or "blanket" or "IVF" so I can just glance at that space and get it all on the next lap.

On a blank spot on the back I make a list of the times. 1900 2000 2100 etc. I write anything I need to do next to a time - that's my goal - do it at that time or by that time. Keeps me reminded of stuff. Helps with meds due at off times. Helps me remember when that 24 hr urine is up or when pt needs to start NPO. Circle as I complete - can clearly see what I've gotten behind on or have ahead of me so I can plan.

Non paperwork tips - always carry more than one thing down the hall. No reason not to pick up a blanket as requested by bed 2 as I return with pain med for bed 1, and drop off dressing supplies in next door room for later since I was going past the storage area for the dressing supplies too.

Always ask pt on initial rounds if they need anything. Then make that note and get it on your next lap.

Pockets - get uniforms with lots of pockets and always put things in the same place. Left leg big pocket - flushes and at least 1 empty syringe (you will be glad). Left little leg pocket - handfull of alcohol wipes. I carry NS flushes, alcohol pads, empty syrings, 2x2's, tape, pens, scissors, pen light, and often extra piggy back tubing (saves walking back when you realize the old one was thrown away by prior shift), marker, couple lancets (trust me it will save steps when an accucheck stick goes bad), sometimes mints and always soda money.

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Specializes in Cardiac/Med Surg.

I like the binder idea, will see what everyone on my floor uses when I start on the 24th. 1/2" or 1", and when I was in leadership one RN who also was an instructor would put all her patients meds in a lab bag with their name on it and put it in her binder. I liked that then and she seemed more organized than some others who kept going back to the med room between each patient. Some of those nurses would put different patients in their pickets and I could definitely see that causing a problem down the road..so I think I like the binder and would probably put picture in from to personalize it!

Thanks for all the great ideas, I downloaded the cheat sheets

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Specializes in Rehab, Med Surg, Home Care.

We're not supposed to pull meds before we give them, even if kept in separate bags in unopened blister-packs. Seems if there's any short cut we can take to get thru the med pass in a timely fashion, they don't want us to do it for one reason or another. (Here's where I use my "critical judgement " and I do it anyway; if we do everything according to TPTB whim-of-the-week the med pass would take up the entire shift!)

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Specializes in Orthopedics.

Our shift starts at 0730 and I usually get there around 7 to look up my labs and get my notebook organized. I find my notebook is my best friend at work. I have phone numbers, dr preferances, meds that i'm not sure about already looked up with there classification and a few other things too that I can't think of right of hand. I also have dividers in my notebook to seperate my patient information. And I made up a sheet for each patient that I make copies of (I write down or circle on my paper whether they have a hemovac/jp tube, their iv fluids and what size their iv needle is, how high they can get their incenative spirometer to, med times for the day and prn meds given, whether they've have n/v, foley output, how much breakfast/lunch/dinner they've eaten, vital signs etc. on my paper. It helps a lot when giving report. I see some nurses write out each of these things on there paper each morning and looks like a waste of time when I can just pull out my handy pt paper. The notebook is bulky and i've thought about getting a clip board that opens but you can't personalize those like you can the notebooks That's how I keep myself organized while I'm at work! And I make notes at the bottom on my page so when I do my assessments I can remember what to type in whenever I get time to sit and chart.

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