what to put on your worksheet?

when i go thru my care plan i make check off boxes for things to do ex- cpm start, occult stool, urine samples. i have a 2 boxes one for labs and info like xrays of tests, the other for a time line ex- oob with PT, dr X here to assess pt, when pt off unit of test/xray. stuff like that. always know their H&H's and INR's or PTT's. and WBC. try to see what it was the day before and see progress or worsening. i have been looking around at other nurse's on the unit's way and using a combo of a few techniques. ask nurse's most of the time tehy will be flattered u asked and say their way is the best way. lol some nurses use a legal pad for stuff they can use as a quick reference of all their pt's on one page. we have a dry erase board in the pt room where u write ur name date and NA's names. i like to write.things like this (here's one of my pt's today) IVF, 2gm NA diet, CPM, SCD's, breathing exercises, ice bag to knee, F/C or make signs in each room to keep ur aides in sinc with u like strict I&O's. lately or census has been flucuating up and down so we all have been floating to different units. so i have been able to see what other units do for shift report. on my ortho unit we give report to our charge report verbally that she keeps in a binder. she gives report to the oncoming charge nurse. that way everyone is in check and knows whats going on, so if ur tied up and can't answer the phone she can let the MD know whats needed. its kinda funny but our ortho dr's have suck a great bond and respect for all of us that some of them we call for orders, tell them what we want ordered and then they give to ok for it. ok off the subject but sorry. i also write all abnormal findings during assessment or changes in status on my care plans. we don't use pre printed report sheets, but the charge does when we give her report. takes time out of ur day but in the end its well worth it. does anyone have to do daily "rounds" where u go into the conference room with a DR and case managers and social workeres and talk about pt's d/c status. had to do that the other day on a PCU floor. felt weird b/c my unit doesn't do that

We just give report to out Nurse Manager and Case Manager in the morning of what things are going on with out patients...our Nurse Manager is good - if we are a bit snowed with our workload she will call Doctors and help out with Patients when she is able to....

On my worksheet I usually have their admit diagnosis, allergies, age etc and accuchecks...I put down who their medical dr/s are , whther they are DNR, what their P/T status is and I&O's whether they have an IV, what diet they are on, LBM, foley. Also make sure i know their labs too....Dr always ask for that....(if they havent looked it up themselves)usually leave a bit of room for a brief medical history too - found this useful if we have ever had a rapid response and the RRTeam have asked what their medical history is...I have seen someone give the worng history to them as they got their Pt's mixed up...

Our unit does not have a "set" form for report. We do use SBAR for transfer pts
The form most of us use is attached. One of our RN's created this form and continues to change it as needed. She is our "form" goddess

The space on the right below 'solution' is where I write labs/tests/xray orders for morning.

We double-side print so we can fit eight pts on each single sheet.