Sorry, I just noticed your post this evening. Let me give you a little help on this. Do you have a report form that the hosptal is supplying for you? Does it include the patient's diagnosis, surgery, surgery date and doctor's name? Those things are important to know because it kind of narrows down the important things you'll want to focus on for each of those patients. The only time I worried about diets is if they are something special like NPO, clear liquids, full liquids or pureed. I usually like to know what labs were to have been drawn that morning for my patients' for two reasons. One, to check to make sure they were done. Two, to check them quickly to see if anything is out of whack that the doctor needs to be notified about. Years have taught me not to depend on a lab technician to call abnormal results to me. Same thing with x-rays. I want to check to see that they are getting done. I don't worry too much about x-ray results because x-ray is pretty good about calling doctors when they see something bad. I used to go through the med sheets of my patients and just check to see what times they were due. On the back of my report sheet I put a little grid with the times I had medications due. I didn't usually write down what medications they were except for IV piggybacks. Sometimes I had to plan out the piggybacks because some patients had two or three different antibiotics that had to be given and some of them were scheduled for the same time. So, I wanted to make sure I got everything all sandwiched in. I also noted by each patient, who had an IV and what fluid was supposed to be running.
For your ortho patients I think I would want to make some kind of indication as to whether the patient had a cast, traction, or external fixation. I'd also list any dressings that needed to be checked and/or changed. I used to make room for the vital signs that would be taken during the shift and blood sugars. As these were done I would also write them on my report sheet. That way I had them and didn't have to go running around to get the nurses notes to find that information. If someone had a foley cather I used to make room for I&O on my sheet, mostly as a reminder to myself to make sure the foley got emptied at the end of my shift and also to check the patient's output just in case I got busy and forgot and the guy turned out to have a ridiculously low urine output that needs to be reported to the doctor.
Right now, off the top of my head, those are the things I would want on my report sheet. Make sure that on your immediate post-op patients that you are checking them for first voiding, what any dressings look like, IV fluids running, and need for pain medication. I never liked the report sheets at any of the places I worked, so when I started using computers years ago I began developing my own report sheets. They were much more functional for me. I used to put the day and date at the top of them. You may laugh, but for all the things I have to do during the shift, it's easier to have the date to look at rather than have to think about what day it is. I also included frequently called telephone extensions (pharmacy, lab, x-ray, transport team, IV team). I used a lot of color also. NPO was always written in red ink on my sheet. Anything that I had to make sure I got done during the shift got circled a couple of times in red ink so it stood out and when I finished it I would just put a slash through it. I used the back of the sheet to write notes, notes on report I took from the ER or OR on a patient I was going to get, and doctor's orders as I took them over the phone. These sheets went home with me in my pocket unless I was required to leave them at work in something other than the trash. I often brought my report sheet from the day before and kept it folded in my opposite pocket so I could refer to it if needed. At home, I kept them in a folder on my desk for at least a couple of months. You never know when a telephone number or a name you jotted down on them in going to be needed again.
These report sheets become very personalized tools for each nurse. You too will develop your syle in one over time. Is there anything else I can help you with? Feel free to PM me.