Here's my run down when I get on the floor:
1. I get report on all of the different patients on the floor from the outgoing shift. I usually go into the rooms with the outgoing shift and the oncoming RN so I can introduce myself to the patients and find out how their pain level is.
2. I print the MAR and figure out when I need to give meds for the rest of my shift and if I need to grab meds for pain tx, I grab them then (I will also get Synthroid at this time). I review the chart for updated MD's orders, out-going shift's assessment, etc.
3. I go into my patient's rooms (with a new glass of water and a pitcher) and do a full head to toe assessment, grab the vitals, blood sugar, whatever information I need. I go over with them the plan of the day, if they have any diagnostic stuff or surgery happening, etc. I usually go over IS with them, if needed. I also usually find out when the last time they have had a bed bath, or shower, and if that's something they would like to do, etc. I make the most of my time with the patients and I do try to cluster care.
4. After I am done, I leave the room, chart all of the information and by this time, it's time to give them their meds for the day and get them up to the shower or ambulating, etc.
When I am not busy, I help answer call lights, observe procedures, offer to do procedures, etc. I do use my own particular sheet but it's not a "short cut" sheet. I don't really know what you mean by short-cuts? I do have a list of times on my sheet and each of my patients have one sheet. I write everything I need on my one little sheet and I'm good to go. By 1000, my CI comes around and expects us to have our top 4 nursing diagnosis for each of our patients and 4 nursing interventions for each of the 4 diagnosis' written down and she will go over that with us. She expects that we know what we are giving the medications for, what side effects to look for, that we've pulled up the hospital procedures and have all supplies ready to go by the time we call her to do a procedure, etc. It's really not as hard as it seems!!! Does this help?