Brain sheets or charting sheets help for new nurse

[Followingfootsteps]

Hello!

I'm a brand new nurse about to start working on a med/surg tele floor and I want to start off as organized as possible! I need help with two things (well probably a million but just two for this post). I would love some help from you, the more experienced nurse. I want to make my own brain sheet but am wondering if you can post yours if you don't mind so I can try and figure out what is helpful and different layouts, etc. ALSO! I'm looking for a sheet (either combined with brain sheet or seperate) to help with areas that I need to chart on, like a little cheat sheet in a way. I feel like I may need something like this in the beginning to help me keep things straight and remember what I need to chart. I'm hoping this sheet will cover the different things I need to remember to write down after my assessments so I can have that to reference while I'm charting. It can also include other areas that I need to remember to check and chart as well. The floor I will work on allows the nurses to use whatever brain sheets they like.

Sorry this is long. Thank you for any help or ideas!

[poppycat, ADN, BSN]

If you use the search function & just enter "brain sheets" you should find a lot. Esme12 has several available.

[cynmrn]

Ok, that looked completely bizarre after copy and pasting it. But, if you go to the website that I mentioned, it's the "Bob" worksheet.

[turtlesRcool]

You can start with one of the pre-done sheets, but my best advice is to make one up based on whatever charting system your hospital uses. Or go based on how you do your assessments. Do you go literally "head to toe" or do you focus on systems? For me, when I'm doing cardiovascular, I'll listen to heart, check pulses and cap refill in all four limbs, and look for edema (lots of CHF patients with edema in their feet/legs). My charting system has the elements of the daily assessment broken into different categories, so that's how I think. Other people literally start at the head and work down. It's really about what you are comfortable with. As long as all the information is there, it doesn't matter HOW you organize it, only that you organize it in a way that works for you.