Just wondering if anyone has made up their own worksheet "brain" (without hospital identifying info of course) to help them remember what needs to get done, looked at, labs, tests, meds, etc, to help keep you on track during your shift? If so, can you post them here for others? I find it extremely helpful to see what other nurses use to help them with time management and keeping track of all that has to be done during a shift, especially for us newbies! I didn't do a search to see if this topic has already been posted, so I apologize if it's already been a topic.
I've been at a few hospitals that had pre-made "report sheets" or paperwork for documentation, but I never really liked using them. They didn't have enough space in the areas that I wanted more space, and included spots for information that I don't write on my sheet.
The easiest this for me to do was take a blank sheet of computer paper and fold it into sections- one section for each patient on my assignment. Then I record the information on each patient in a way that is organized and makes sense for me. Each patient's section looks like this:
Top line: Room# Pt's name, MR #, age, birthdate, diagnosis and their physician's name and contact extension.
The next part of the section is divided into three vertical colunms.
Column 1: (In no particular order) Significant co-morbidities, diet, allergies, code status, vital sign frequency, important lab results, tests and procedures scheduled for that day.
Column 2: Lab results that I need to check that morning (I leave a blank line to write in the value). Scheduled nursing skills (ie. wound care, bed bath, IV checks, trach care, suctioning, neuro checks, etc. with the time the task is due and a box to check indicating completion.)
Column 3: Times that medications are due, again with a box to check indicating completion or a line if it is a titrated or sliding scale dose.
The bottom line is important notes that I make throughout the shift to remind myself of info to pass on to the next nurse.
So it looks something like this:
101: Jane Doe, MR 111111, age 11, DOB 01-01-2001, Cystic Fibrosis, Dr. X, ext. 123
Diabetes, Type 1
High-protein, high cal diet
RFT @ 1000 bedside
Chest PT 0800__, 1200__
0730 Blood glucose__ insulin__ units
1130 Blood glucose__ insulin__units
*Pt performs own blood glucose monitoring and insulin injections. *
Of course, my own sheets include a lot more information!
Last edit by Double-Helix on Jul 4, '11