Advice please!

I feel the same way!! 6th week on orientation on step down cardiac floor. I feel like an idiot when I give report. I try my best to keep organized with all that went on throughout the day for the main purpose of change of shift report. Change in meds, doc orders, etc. Because I have felt stupid about forgetting these things during report, it has made me develop a habit of writing them down on my "rounds report" (which is the sheet we get that summarizes what is going on with the patient... Not sure if every hospital uses them or calls it that).

Anyway, what I do to organize, which is working for me, I use the rounds report throughout the day and that is where I write all my information. I get to work 45 early, print out all rounds reports on my patients, highlight important info, then look up labs. If I have time, I look up radiology tests. I also find extremely useful doctors reports because that gives you a quick snapshot of the patient plus the patients history. On the front of my rounds report I have several boxes, one contains the labs, another box is for my assessment, another box is for vitals and another for blood sugars, and a box for "to do" throughout the day to keep on task. On the back of my rounds report, I write shift report on the top, on the left i write shift reports assessment, on the right is a box for "open" procedures, on the bottom is for doctors orders and med changes. So I have everything I need for that one patient all on this rounds report that I carry around all day and update throughout the day. It's working for me and took me 6 weeks to figure out! Ugh. It still needs perfecting but I feel really good about it. It keeps me organized.

I love reading these posts because I feel so inadequate everyday at work, I beat myself up for making stupid mistakes. Like I don't know what it is but I can't keep all these details in my head like my preceptor does. I am improving though. Just taking one day at a time.