Hi, tmoney! I am one of those nurses who writes my brain down. I like to write things down like Chris does, but this is how I do it:
1. Take a sheet of paper.
2. Make a column for each patient going down the paper.
3. Go across and make a block going across the top of the paper: Put the pt and room number. With this info, you can put "ISO" as a reminder that they are on ISO or "D/C" if they are going home. These 2 things are not necessary though.
4. Make another block by drawing a line across. A (assessments): 8 12 4. (Of course do what your floor is for assessments.). This way, you can draw a line through the numbers respectively after you have charted these assessments.
5. Below "A" in this same block: Write a "M" (meds) with the times they are due: 8 12 16 18. Draw lines through these numbers after you are done with the med admin.
6. Now, draw a line across further down the page so that you have a large rectangle within your column: jot down important labs you want to follow up on as well as tasks that need accomplished. DO NOT BOTHER to write down a time to execute tasks unless it is a time specific one because you will be interruped and your day will be chaos. Mark across after you have completed your tasks.
7. If you pt is on telemetry, you can also make a box going across just for tele: "SR 80s, SR 60s" to track what they have been running all day cardiac wise at a glimpse.
The trick is to make this work for you. Your way of doing things must be efficient. You do not have the time to write long sentences for tasks and so forth. When you come in to your shift, grab your charts, sit down, and review orders for the past day or so. Make your sheet as I have described. Look up your lab values, and write down important ones that you need to follow up on or simply know. Look at their blood pressures and write down their current and baseline so you know their normal b/p and if there is an issue. This is how I do things. You must be efficient so that you can hit the floor running with your patient care.
I hope that this helps. If you need me, my name is really Kasandra. Most call me Kat. Write me on here. I will be here for you. Do not give up on yourself: Be patient and ASK QUESTIONS. Cocky nurses hurt or kill people with mistakes that could have been prevented. This is not you! Remain humble and your patients and colleagues will love and trust you for it!