I print out a copy of my assignment sketch out my plan. The sheet pre-prints name, room, physician, diagnosis, and I add diet details, how pt transfers,
A (assessment if needed)
F (reminder to do a fall assessment if they don't get a full assessment)
CP (care plan)
FIM (for those needing a fim)
CARES (for those not needing a bath)
BATH (for those who do need a bath)
ADMIT or DISCHARGE (so I don't forget the steps - complete the admit screen, FHA, education or resolve the care plan and education)
Then I fold the sheet in half and on the other side, I have space for med times that can be crossed off, I/O details, dressing changes, treatments, tests, and to add other details I need to report off on.
I'm sure I have other details I jot down out of habit that I can't think of, but I hope that helps out a little bit.