Need good ideas on how to write labs down

  1. As a student, I've seen nurses write out different formats for keeping track of their patient's lab values -- but I obviously was not smart enough to write these on any papers I could keep (pt confidentiality). Now that I've just graduated, I feel this information would be really useful.
    It will probably be hard to describe these as they are drawn out like arrows, etc., but any help you could give me would be greatly appreciated.
    Last edit by kayjo on Dec 18, '06
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  2. 3 Comments

  3. by   nurseangel47
    You may want to customize your own report sheet incorporating a column for important lab values, then just jot them inside the space w/abbrev such as H/H for hemoglobin/hematocrit, etc. While getting report, if the offgoing nurse throws out pertinent labs and/or labs that are pending and vital to call to the doc., jot that down, too in the lab space you've included in the report sheet. Lots of new nurses are using their own report sheets as I've seen in here for info. requested to do so and any ideas from seasoned nurses for what should be on them. Sometimes the ones in the hospitals are too generic. If you're not computer savvy, maybe a clerical person where you work would do it for you, or another fellow nurse who is knowledgeable of computers' formatting to make up a sheet for you to use.
    Make and keep enough blank copies so you don't run out and have to start over from scratch! (this is something I'd be prone to forget about!) Good luck!
  4. by   UM Review RN
    I just write the ones that are way off in a shorthand I can understand. I'm not much of an artist and those crazy little drawings are cool when someone else does them but unintelligible when I do them.

    An example: H: 8.3, Creat 3.1, INR 5.2 (MVR Pt)

    All of which means that Pt has a Hgb of 8.3 (we think about transfusing anything less than 9), and with a Creat of 3.1, is in renal failure, and the INR is high but this Pt does need to have an INR of around 3.0 anyway, because this patient has had a Mitral Valve Replacement.

    These are all very common examples of labs that I would want to keep an eye on and report to the doc.
  5. by   Ruby Vee
    Your hospital generally has a format for writing labs in the physician's notes. It could go something like this:


    Sodium | Potassium | BUN
    ---------------------------/ Glucose
    Chloride| CO2 \ Creatnine

    (Is that what you meant by the arrow thing?) The positions of Na, K+, Cl and CO2 are often switched around. If you figure out which configuration your hospital uses and get used to doing it that way, all you'll have to to is draw out your arrow thing and plug in the numbers.

    I also use: PTT/X mean
    PT/INR

    And hemoglobin (or hemtocrit) \WBC/platelets

    (Gee, I hope this comes across when I post it!)

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