How do YOU keep up with assessments?

Nurses General Nursing

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Specializes in Pain Management, RN experience was in ER.

I was wondering what everyone's systems were for keeing up with assessment data on a patient? I know that a FEW of us are lucky enough to make it to a computer RIGHT after assessing a patient, but how does everyone else do it? On just a scratch sheet of paper? Did you make an assessment form of your own? Do you have one to share =)? Just curious what everyone's system is. I dont know how to make my own! I'm just a nurse tech, but I'm trying to be organized NOW so I can make it a habit. We still have LOADS to chart even as a nurse tech and tomorrow is my first day. As a CNA I didnt have anything to chart but ADLs, vitals, I&O, and safety checks. I'm scared! I know that I can learn from nurses at work, but how do YOU do it?

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Specializes in Med-surg; OB/Well baby; pulmonology; RTS.

Our computers that we chart everything on are on wheels and we are encouraged to take them into our pt. rooms with us and chart our assessment as we go (the only exception being isolation rooms of course). Otherwise I write down little notes and do so especially in a crisis situation.

Do pay attention to what other nurses do but you will eventially work out your own system.

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Specializes in Cardiac Telemetry, ED.

I use a worksheet with space for assessments and jot notes as I go. Later, when I can make it to a computer, I chart my assessments.

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Specializes in RN- Med/surg.

I'm still new..and discovering what works for me. Luckily we have computers in all the rooms. Usually I just jot down abnormal assessments on my brains. If there are alot of abnormals...I chart in the room before leaving.

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Hello, my name is jodi and I love your question. I go to Glenville State College in West Virginia and I have two more years to go until I get my BA in nursing. My care plan is 8 pages long and I thank God I have that outline. When I first started having to use it, I thought I would never get done; however, with time it is like cleaning house, you know what needs to be done and you do it. If you would like to see my care plan I would love to share it with you. The care plan is long, but it makes you think about the whole picture. At the end of this semester, I was seeing things that fell right in place. I started looking for signs and once I found a problem, I knew how to deal with it. I hope that I helped you. Again, if you would like to see my care plan, I would love to share it. Jodi

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Specializes in Med/Surg, Tele, IM, OB/GYN, neuro, GI.

I have a general assessment that I made for clinicals. I attached it if it doesn't work pm your email address and I'll email it to you. It's only two pages so I just copy it front and back.

general assessment.doc

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Specializes in Community, OB, Nursery.

I jot down anything out of the ordinary either on my brains or on a paper towel. I try to keep the chart at or near the bedside & write as I go, but we all know it doesn't always happen that way! :)

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Here's a very simple sheet I used when I worked as a student nurse associate. I don't have any dietary info on here because I didn't have to deal with trays on my shift. Good luck!

SNA worksheet.doc

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Specializes in med/surg, telemetry, IV therapy, mgmt.

here are two websites that have some report and worksheets:

there is a thread on the nursing student forums that has links to all kinds of assessment information. i don't know if there is a particular form there for what you are looking for. i have, over the years, created my own report sheets that i used at work because no place ever had a form that suited my purposes. they are not really hard to do on today's computers using word. it's just takes patience and some time invested in learning to use the various commands in the word programming.

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Specializes in Pain Management, RN experience was in ER.
Hello, my name is jodi and I love your question. I go to Glenville State College in West Virginia and I have two more years to go until I get my BA in nursing. My care plan is 8 pages long and I thank God I have that outline. When I first started having to use it, I thought I would never get done; however, with time it is like cleaning house, you know what needs to be done and you do it. If you would like to see my care plan I would love to share it with you. The care plan is long, but it makes you think about the whole picture. At the end of this semester, I was seeing things that fell right in place. I started looking for signs and once I found a problem, I knew how to deal with it. I hope that I helped you. Again, if you would like to see my care plan, I would love to share it. Jodi

Thank you everyone for all of your help! Yall are amazing! And Jodi, I'd love to see yours as well! I love trying out other's ideas and then tweaking them to fit mine. You all have been so helpful!

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Specializes in Med/Surg and Wound Care, PACU.

after working in med/surg for over 6 years i had it down, most of the time if it was not a crisis situation i just remembered everything, i am fortunate that i can remember even the smallest things,

in crisis situations i do use a sheet of paper and write down time and what happened other than that i use my brains

nici

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