Does anyone have a good layout for your brains? When I was in nursing school it was given to us for the first 3 semesters, then we had the opportunity to make our own and play with other's as well. I always felt organized but something happened between then and now!
I first started as a GN in June and wrote report on one piece of paper that was separated for each pt. I then had a matching piece of paper with only rm#, pt name and important information that I used during the day along with the med sheet (we computer chart). After I failed the NCLEX the first time I worked as a CNA from Aug. until Dec. and again used the same format but only had to record vitals and ADL's on it.
Now that I am practicing as a nurse I feel like I am so unorganized and seem to end up with a million different papers and only have 2-3 pt's. What happened to me? I have no format for recording and keeping track of my pt information during the day and feel as if I completely forgot how.
We get report on all pt's at the beginning of shift (work in family care so have PEDS, PP, L/D, and some surg) then at the end of report we delegate the pt's to each RN. I am wanting to find a simple layout that will allow me to keep my information on just a few sheets (know I will have more pt's when off on my own) and maybe 2 pt's per sheet with organized layout for: Report, pt information, meds, interventions, ADL's, and VS etc... I know if I can get myself organized again I will be much better at giving report too. Nobody in my unit really seems to use anything but a blank piece of paper when report begins, but they all seem to have their own little things they use to keep it all together.
Has anyone come up with a good idea or am I the only one who has already forgot what I learned from nursing school on how to be (and remain throughout the day) organized?