I have some sheets that I use as well, somewhat similar to yours but a little different. I find them quite helpful. For some reason, the only one that I can find is the one that I use if I float to a medsurg type area--I think that I saved over the one that I use for critical care. They are pretty similar though, the one for critical care only has two patients per side, has more room for the dx/IVFs/and empty space for me to fill in anything necessary.
Top left of the posted page is pretty self explanatory:
Patient, allergies, room number, doctor, activity (act), IV sites, iv fluids, cbs frequency and level, VS (q4, 6, or 8 and times...) pain level and area.
Under the systems, I write notes about my findings for each system. On the right of the chart I have the times: I write in meds/cbs'/labs or anything else that needs to be done . I don't usually handwrite all the meds, I just put and M in the box to remind me to check the mar (plus that way I don't get lazy and only go off the sheet)
In the admit section, I write what they are admitted for. In the history section, any pertinant history. Blank spaces are for anything that some up that I need to tell the oncoming shift.
It seems like a lot but really, it only takes me a few minutes to fill out. If i get busy I can just glance at the sheet and see what I have to do when, I don't have to remember all of the patients histories or so back to the chart. You can double side the document and have all six patients on one piece of paper. If you get busy with a crashing patient, someone else can look at the sheet and fill in for you without digging through the charts. Ok--so that was really longwinded. I find that I rely on using this less now that I have more experience but I still fill it out--habit I guess. Anyway, feel free to use it or change it or whatever!
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Assessment / Report Data Sheet Organizer
