What do you use as your "brain" while on the job?

Mandy LVN · Jul 5, 2011

I had my husband make this up for me a number of years ago...I think it works great. If I run out of room on the front d/t changes in condition, just fold the bottom up and write on the back. I change things on it from time to time, but the majority of it has stayed the same for years now. Good luck!

Date:_________________

Name:

Rm#:

Age:

Dx:

Dr:

Hx:

Allergies:

Meds

Diet:

0700:

Activity:

0800:

IV Site:

0900:

1000:

IV Solution:

1100:

1200:

1300:

Foley:

1400:

Labs:

1500:

1600:

1700:

O2 @

1800:

VS:

1900:

Tele:

Updrafts:

Comments:

Mandy LVN · Jul 5, 2011

Hmm that didn't work out like I expected it to....not sure how to correct it.

Double-Helix, BSN, RN · Jul 5, 2011

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

Allergies: pennicillin

NS 50ml/hr

Hemolobin__

Chest PT 0800__, 1200__

Hygiene care__

Port-a-cath check__

Medications @

0730 Blood glucose__ insulin__ units

0800__

1000__

1130 Blood glucose__ insulin__units

*Pt performs own blood glucose monitoring and insulin injections. *

Of course, my own sheets include a lot more information!

LouisVRN, RN · Jul 5, 2011

i use the hospital report sheets as most of the information including consults, diet, activity, equipment (scds, is, cpm, etc) and then fill in the blank regarding pain medication, iv fluids gauge and insertion date, last bm,

we use sbar so the report sheet looks something like this:

john doe 53 male

dr. smith

pmh: htn, dm ii, cad, cabg x3 2008

admitted for: total knee arthroplasty

(all above information is pre-printed onto the 'brain')

s: ____________________________________________________________________________________________________________________________________________________________________________________________________

(here you can list anything that is planned for this shift, such as pt to have x-ray left knee, call dr smith with results, ce at 2000, 0400 call if dr jones if elevated)

b:

____________________________________________________________________________________________________________________________________________________________________________________________________

(here you can list previous diagnostic test or anything that may not have been listed elsewhere -[color=rgb(153, 50, 204)] ekg 7/4/11 wnl, complained of chest pain post-op ce x3 ordered, first set wnl)

also there are preprinted categories that you can fill in

diet: [color=rgb(153, 50, 204)]cardiac

iv: [color=rgb(153, 50, 204)]20g l fa placed 7/3/11, ns @ 100cc/hr sl with good po

a: is preprinted with categories our charting documentation categories:

neurological

respiratory

cardiac

musculoskeletal

when orders are written they are input under the documentation category and thus the orders will appear on the profile.

for example:

wounds

[color=rgb(153, 50, 204)]7/3/11 keep dressing cdi. remove dressing pod2, cleanse with alcohol and apply simple dressing.

activity

[color=rgb(153, 50, 204)]7/3/11 pt bid wbat with fww

overall i really like our "brains". however for important information that i need to complete during my shift nothing beats an old-fashioned post it note with a blank box drawn next to it so i can make sure to check things off as i get them accomplished.

llerkl, ADN · Jul 5, 2011

When I worked in the Neuro ICU, I used to rip off a piece of EKG paper, label the back of it by the hour. Wrote down whatever was due each hour (12 hr shift) such as labs, vs, meds etc. and carried it in my pocket. Worked like a charm! Of course I never had more than 2 patients, so it was easy to make 2 columns, one for each patient's needs.

beckster_01, BSN, RN · Jul 5, 2011

I use the hospital report sheet because it is very simple, basically it has 6 rows and 4 columns. The first column I write pt demographics (name, age, diagnosis, significant allergies). The second I write significant medical history, info that I get in report, tubes/drains, etc. I usually leave room for a to do list (walks, flushing lines, orders that I need an MD to write). The next column I write down med times, tele, and insulin, then put boxes next to each category so I can check them off as I go along. The last column I don't usually use but will write labs if I need to.

I don't like using report sheets with specifics because if something isn't significant I don't write it down, and it takes up room that I want to use for more important information

Ivanna_Nurse, BSN, RN · Jul 5, 2011

we have a shift report sheet as well... its pretty informative, so all i do is take a piece of paper, write down the systems and note what I need to as i go. mine includes med times, accucheck times, tubing changes, labs needed, and pending tests. I also make part of it my wish list.... for what my pt needs when the intensivist comes by. I keep the same sheet the whole stretch i work. Ivanna

JRP1120, RN · Jul 5, 2011

These are great!

Florence NightinFAIL, BSN, RN · Jul 5, 2011

Mine goes something like this:

Doe, Jane, 86 F, Dr. James

Dx: Rectal Ca

Sx: Anterior resection, POD 4

Hx: Diab, HTN, CVA, Gout

DAT/AAT/D5.45NS@ 125

Lap sites drsg___

Foley___

JP___

Gluc QID__

Meds: 8 12 16 18

Gluc: 8 12 17

In/Out: 12 18

Labs:

Other:

I tweak it regularly based on each pt but that's the rough outline.

Bortaz, MSN, RN · Jul 5, 2011

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 created one after my first week as a new nurse, because I needed more structure than the one on my unit provided. It's for a NICU, though, so doubt it'd be helpful for you. So, I guess my point is...try creating one that you, specifically, are comfortable with?

Mine is an excel form, so I can't attach it, but I'll send it to you if you think you need/want it. Just PM me.

chicookie, BSN, RN · Jul 5, 2011

Along with a paper with my "brain" on it, I used my iPhone. I set alarms for medications that were at different times such as 2pm or 4pm. I also have an app called Errands. You can make a check off list on it. so I had the other stuff on there. For example I have 6 lists and I can adjust the room numbers on it. I have morning assessment, morning charting, morning meds, check orders, New orders done, etc. I have check orders in 5 different places on there because my biggest problem was forgetting to check orders at different times. It really helped me stay organized and not feeling so overwhelmed. Plus I could just look and say charting done for rooms 1, 3, 5,6 next up 2 and 4 etc. After a while I stopped using it as often because it has become second nature to me. But it really helped alot.