Published Jul 23, 2009
erin01
158 Posts
so i have down loaded a few sheets from here to try to help my day. But i seem to have a total mess by the end of the shift. I am scribbling all over the paper with things to do or vs or labs. And by the time i go to give report i am a mess. And how do you guys remember everything you asses? i tried this weekend to scribble on the back of the paper to see if it would help and leave all the import info alone on the front! Still feel so all over the place=( any suggestions?
Diaper, RN
87 Posts
Depends on the unit that you're working, I usually print them out by systems such as:
Pt's name Room no Code status
Dx: Past History: Dr: Diet:
Restraints:
Activitiy:
Neuro
Respiratory
Cardiac,
GI
GU
Wound
IV / PICC
Follow up item:
Goal:
NotReady4PrimeTime, RN
5 Articles; 7,358 Posts
It gets easier over time to remember the important info you need to pass on. I wouldn't bother writing every little thing down for later, just what is outside of the norm. If the patient's VS are all within normal limits, that's what you report. If the hemoglobin was 128 at the start of the shift and it's 98 now, you can surmise that there's been blood loss somewhere (or they're really fluid-overloaded, but you'd remember the 2 L fluid bolus!) and you'd report that. The more you stress about it, the more stressful it'll be.