New grad, please Help with med surg organization!! - page 3
Ok. I just completed my first day on the floor. I feel horrible, there was no structure to the day, I was just thrown out there to care for five patients with my preceptor. I know my organizational skills are severely lacking... Read More
- 0Jan 18, '13 by PediLove2147Quote from RachelRN89I am so happy to hear that! I love my report sheet so I like hearing it's helped others as well!PediLove2147,
I just wanted to tell you that I thankfully stumbled upon this thread and looked at the brain sheet you created and posted. I have been using it for the past 2 weeks or so and it has helped me out so much! I feel more organized with it and my report to the next shift seems to flow 10x better when I'm using it. I just wanted you to know that I've benefited from using it. Thanks again!!
- 0Jan 23, '13 by ZLadyI would like to share what is on our "Report Sheet" or Structured handoff sheet. At the top, you include the Name,Age, Admit Date, Doctor, Hippa info, & Diagnosis. You need to know the patient's Past Medical History. You also will need to know their Allergies, as well as Isolation Type, Code Status, and what language they speak and their Height and Weight. Our sheets then follow the report by systems. This section starts with Neuro and a place to write in what their status is (AOX3 or "May have Confusion at nighttime"). Respiratory is next with lung sounds and any O2 or breathing treatments or Trach information. Next is Cardiac. You would include any information regarding the Cardiac status, such as murmurs or edema etc and any VTE prevention. After that is IV, site, and date, with IVF. GI system with ordered diet, Date of last BM, ? Ostomy, any Tube Feedings, and assessment of the GI system is included. You also want to cover the Urinary or GU with method of voiding, catheter information etc. A place for skin assessment and any treatments needed would be included. There should be a place for Procedures that were done this hospitalization. Included a place for VS and Lab results. Also include I&O. PRN medications and Pain Medications should be included. This should give you a good start. I am happy to say, we will be switching to EPIC very soon, which will have all that information included in the EMR with just a click and on one screen. I am so ready. I hope that helps.
- 2Jan 29, '13 by GenistaTo the OP- One thing that I copied as a new grad from another RN was the idea of an hourly "to do" list/timeline in addition to the "brain sheet" (I incorporated it into my "brain" sheet). I would write in each hour for my shift (I work pms), and then fill in when meds or treatments were due for my current shift. Something like this...I would put the room number of the patient and an "X" by the room if they had more than one medication due at that time). Example below is an hourly example of a pm shift starting at 1500 (3 pm):
1500-Rm 222x, Rm 232x
1700-Rm 222 accucheck
1800-Rm 222 TPN
2000-Dressing change Rm 222
2100-Rm 222x and accucheck, Rm 232x, Rm 243x, RM 252x
2200-Lab draw Rm 232
The beauty of this, was you are able to see where the bulk of your medpass is when the shift first starts and work around that. I would cross off the room number as I finished the med pass/treatment, etc. If there are certain hours in your shift where there are few meds/treatments, you can utilize this to plan for as needed tasks that you hope to complete...i.e. ambulating a patient, some teaching you want to do, maybe a PICC line dressing change is due, or whatever else needs to be done. You're working around med times, but also can write in reminders such as if you need to check the result of a lab draw (ie. a vanco level, etc) or a timed draw, etc. I found it very helpful to keep me on track, especially when there are so many distractions.Last edit by Genista on Jan 29, '13