Brains???? What's on yours

Nurses New Nurse

Updated:   Published

Hi all,

I am a RN Student who is looking for a great form to use as my brain. So I am able to track all my information neatly and accurately and be able to read off my report orderly. Thanks for the help.....

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Let me see if I can do this from memory... its pretty standard... 3 columns per pt, and 2 pts per side of the paper...

Column 1

Name/Age/Sex

Dr

Dx

Hx

Allergy

Code

I/O

Diet

IV location/guage

IV Fluids

Labs: Chem 7, CBC.. (fishone diagrams)

Wt/Ht

Column 2

Neuro

Cardio

Resp

GI

GU

Skin

Musc

Pain/Psych

Column 3

General stuff I want to add from report

Things I need to remember to report to MD, etc

Things that need to get done.

Special occurances, verbal/telephone orders.

That's the basics... though, its not what the form LOOKS like... its what you put on it... =)

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Specializes in Clinical exp in OB, psy, med-surg, peds.

Wow that's a great way to remember, all the best

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Specializes in Trauma/Stepdown, CCU.

We usually print out our kardex's and then I highlight name,room, dx, activity, diet, MIVF, scheduled meds and any new orders that are on there for my shift.

I usually write whatever I need to from report on the top of each pt kardex..

then I make a cover sheet... I have 6 boxes on one sheet... one for each pt. I have the room # in each corner.. And then in the boxes I have meds with the times they're to be given ( and a place to check things off ) any drains,tubes,dsg changes, flushes, finger sticks, and any other routine things I need to do or check during the night. If its not checked off.. it reminds me that still needs done. =)

Then if i need to refer to my kardex, its all there. =)

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That's a great question and thank you for all the replies as well! I am also a new RN and those tips will help me a lot!

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Specializes in Clinical exp in OB, psy, med-surg, peds.

My brains are fried today, just finishing working 16 hours, LOL.

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Specializes in OB, ortho/neuro, home care, office.

If you want a copy of my brains PM me your email address and I'll send you my brain worksheet. I have had many complements on it. I figured out how to attach my brain.

Report sheet (2).doc

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Specializes in Clinical exp in OB, psy, med-surg, peds.

Yes Jen that is a good thing ccan you send it to me too, am having trouble keeping up with the paste

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Thanks Jen

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