Color Coding SBARR and/or Patient Notes

jbecerra · Jun 24, 2013

Accu checks in red pen. Any antibiotics in red pen( with the dosage time, like Cipro 0600. Dressing change instructions followed by a red line to be checked when completed. Labs in red on the back of my report sheet. Anything special or anything to be watching for, put it in red or underline it in red. I also follow a sort of a grid on my report sheet; the history always goes in the right margin, antibiotics and accu checks in the lower left corner. Cross them off with black pen (and the time) when they're done. Also keep record of calls to MD, what time,orders received. Hope this helps!! We all adopt a system that works for us

jadelpn, LPN, EMT-B · Jun 24, 2013

Our unit passes out "brains" (SBAR sheets). You could suggest that you all start with the same sheet. This way, if you spot someone for lunch or a break, you all have the same master list, and vaugely familiar with all the patients, not just your own. I like a boxed sheet, where the patients are listed in the left column going down, and across follows the same pattern (OK, I am a tad type "A" LOL). Box 1 has patient name, demographics. Box 2 has admission dx. PMH allergies. Box 3 pertainent test results. 4 diet, ambulation orders, that other discipline notes. Last box mich. info.

I highlight my patients, write any notes in black on the sheet during report. I fold the paper so that only the names are showing, and do a quick med/order review, and note in blue any variation of the norm--for instance if a lab is to be done at 11 am, or a med is to be given at 1pm....just as a reminder. Crossed out when completed. In red, I do pain med given and time, turn and repo times, anything that requires me to repeat in a certain time. Finally, in green any orders or other items that I need to speak to the MD about, or social work for discharge, reminders about patient education pamplets, anything I need to remember to report off at shift change, that type of thing. The most important part of this process is to take out your sheet and look at it every hour.

There are other nurses who have their own "kardex" system, and have a sheet per patient, on a clip board. That is where they keep track of their notes. Some take it up a notch, and do all of their notes in blue, and in the case of continuity of care, then pass the entire sheet off to the oncoming nurse, who notes in red, who hands off and next nurse does in green. Then passes onto the next day--the original nurse, who continues to use the sheet and so on until the person is discharged. Pretty cool system, but lots of paper and again, something you need to refer to at least every hour for it to be effective. Some emr's have the ability to print out 24 hour summaries. Which is a cool option, and gives a general overview of the patient. For me, having a "brain" of any kind means little until I can review orders and meds. That helps me to put things into perspective.

I have seen those pens that click down either red, black, blue, or green ink. Some use flair markers in varying colors. When I look for scrubs, I like the pockets--more the better (without getting too crazy) so that everything is in my pockets I need pen wise.

Good luck, and let us know what worked!!

MunoRN, RN · Jun 24, 2013

I guess I'm a little dense, but why would you color code and SBARR?

SaoirseRN · Jun 24, 2013

Rather than highlighting, I write out my sheet the same way each time in a system developed throughout school. I know where to look for what I need because it's always in the same place. The only thing that goes in red is DNR.

Nurse Kyles, BSN, RN · Jun 24, 2013

I take report on my report sheet in red. I write all my notes throughout the day in black. This way I can easily differentiate what has changed throughout my shift.