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.
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!
Nov 18, '06
I use a clipboard to keep my nsg notes on (we chart by hand). As I do my initial assessment I chart right then there. When I am through seeing all my pts my charting is done. Then all I have to do is add to it as needed throught the night. I see a lot of nurses that don't even start to chart until 0200-0300....this would drive me nuts!
I have a brain sheet I keep in my pocket w/pts name,age,dnr status,admit date,room #, doctor, dx, hx ( brief) allergies, tubes, drains, lines, tx, labs, tests, sx, diet, iv sites, fluids, pca, dsg, nebs, vs w/o2 sats, accu cks, activity, on it. I have a note section at the end for things need to be done/passed on. If I need to know something through my shift I look at it & update as I go, then I give report from this. We do report face to face...I usually make a copy of my sheet & give it to the next person. This helps speed up report & keeps things from getting left out.
I look at my MAR as soon as I get report to see how heavy they are!(ours are paper & kept in a binder in the med room). I also keep a current vitals list w/my MARS. I go in at 1900 so those meds are already done...I check just in case. Then at 2100 I give my 2000, 2100, & 2200 meds & do anything else scheduled in that time frame, chart if needed. At 0000 I do the 2300, 0000, 0100 meds, chart. I do this all through the night & it keeps me on schedule & allows a little time for the unexpected things that happen. There have been a couple of days when... I could have cloned my self & that would not even have helped!
but for most days it works great!
BTW...when I pull my meds I do them all at once...I put each pts meds w/MAR in a zip lock bag & label it. I don't open the meds until I am in the room & use the MAR to double check the med, pt & tell them what they are getting. This saves me a lot of steps!
Last edit by crb613 on Nov 18, '06