I've developed a bad habit that's totally bit me in the you-know-where. I work on a med/surg unit that has 16 beds, my usual patient load is six to seven patients, and I get pretty busy most of the time. When I receive report at the beginning of the shift, I write down the assessments of the previous shift on my report sheet (lung sounds, bowel tones, colors of any drainage, etc.). I go do my assessments, then, if I assess something different in that patient from what I heard in report, I'll make a note of the new finding on that sheet by writing it down. If nothing has changed, I'll just circle the note I made during report, and then document what I circled as my finding. Then when I give a verbal report to the charge nurse in the middle of the shift, I just go by the report sheet. This has saved me time, but it's cost me a few things. What's happened as a result of doing this is that sometimes, I'll mistakenly circle "decreased lungs" when I heard them to be clear, then I'll relay the wrong information to the charge nurse. Sometimes, I'll say something like, "The stoma is pink...no wait, I'm sorry, it's really beefy red" when I've read the incorrect assessment note and corrected myself. This either results in my getting lectured for appearing to second guess myself, or what's worse, getting accused of not doing my assessments and just telling the charge what was going last shift and saying that that was MY assessment. The charge nurse assumes this because I'm reading from my report sheet. I can't really explain myself, because this certain nurse yells at me for making excuses, so I've just learned to say, "You're right, I'm sorry." Ugh.
So, I've decided that instead of fighting her, I'll just improve myself and what I need to do. What I'm asking is, is there something online that I can use as a resource, or does some have a template that they use at work that they helps them make notes from their assessments? I'd like a "cheat sheet" that allows me to quickly (and accurately) make note of what I've assessed, and maybe even lets me fill in the blank of what IV fluid and rate the patient is getting, diet order, etc. I thought that my usual way of just circling each finding would save me time. It does, but it's not 100% reliable for me. I've learned that to do a good job, I need more structure and preparation. If no one has a template to offer, can anyone suggest anything else that's helped them that might help me succeed? I really want to make this change.
Nov 16, '05
I found myself doing something similar when I first started. I would write detailed notes from report r/t the previous nurses assessment. I found it was influencing mine when I went in to check the patient. Now, I don't write any of the previous nurses assessment down.
On my patient sheet I leave blank spaces to fill in the following blanks:
Pt Name/Room Number/Allergies (I put these in red)/Age/Total (if pt is total care)/DNR (if they are one. I also star this and put it in red)
Activity/Equipment (braces. SCDs, etc)
IV(I note type of maintnance fluids, site, line type)
Meds (I just note times)
VS (Frequency. I also leave room to write any that aren't WNL for my report later)
Neuro Checks (I'm on a Neuro Floor)
Accu Checks ( I write the times and fill in the readings and coverage as needed)
Foley (Yes or No)
I&O (Is patient on? Is it strict?)
O2-(How much? Type of appliance. I also note here if pt is on continuous pulse ox. )
In the second column I leave space to write any tests, consults, etc that need done and blank boxes to check when complete. ( I do these in green.) Then I leave a small space for notes either from report at the beginning of the shift or mine throughout the day.
I finally settled on the above template and it has been working pretty well. The really nice thing about it is that I can just use a blank piece of paper folded into fours. I found that sometimes a pre-printed form does not always allow flexibility if I need more space in a particular category. For example, many of my patients have an extensive history. I can have up to 6 pts during the day so I use the front and back. There are two extra spaces for new admits. I can always grab a second sheet if necessary. It fits nicely in a pocket folded into fours so I'm not constantly leaving it somewhere like I did with my clipboard.
Last edit by NurseyBaby'05 on Nov 16, '05