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.
