Quote from momof1
HI everyone! i'm a new nurse
and completely unorganized. can someone send me some examples of worksheets used to organize your pt information. By the end of the day i find myself with pockets full of papers and information everywhere. when i report off it is chaotic and not straight to the point. someone please help! i work on a med-surg unit. discharging 2-3 pt. per nurse a day and admitting the same.
I worked out of a small (5x8) notebook. I worked in ICU where I had only one or two patients, so you will have to work on a legal pad. But when I floated to the telemetry units, I used their pre- printed work sheets.
I put my report on the top for my patients, by system. I then wrote a timeline for all the hours I was there. For example:
08 Chem sticks, VS
09 Keflex 1 gram IV
I would leave 2- 3 lines to fill in for each hour. I would cross of item as I did them.
I would then work off of the kardex and plug in the things that needed to be done at those hours, meds, chem sticks, labs. I would also add baths IV and line changes, etc. I would add to this as the day wore on and I got more orders, or changed orders for the docs. I would add if my patient had to go for a test, or something. I saved these notebooks. I always felt if I had a problem with the hospital, and they accused me of not doing something, etc. or heavan forbid, a law suit, I had written proof of my daily activities and care. It would also had used these as proof to the board of nursing if I was accused by the hospital of some form of negligence, or something that I would have had problems with the board over. In other words, I had written response/proof to their accusations. This is what I meant in my other posts about practicing "defensive employment". So many times the hospitals use minor, but trumped up accusations against nurses that they want to get rid of for what ever the reason. On this listserve, there have been a couple of recent situations, where nurses faced retalitiatory discharges over minor, but trumped up complaints. Incluiding ther nurse who just won a law suit against the hospital for being fired. Show your written proof of the type of nursing care that you practiced and provided to your patients, and shove it in the face of the board of nursing and the hospital administration.
Be sure to show it to your lawyer, as well. He or she can then ask for a summary judgement and have the lawsuit dismissed.
Again, it will take a little practice, but it will be second nature after a while. You will have to adjust this to your work situation, but it can work. Hope that this helps.
Lindarn, RN, BSN, CCRN