Daily Cheat Sheet?

I would include allergies,

date of birth,

current date,

IV

I would include allergies,

date of birth,

current date,

IV

Allergies, d'oh!

I could change age to DOB.

Date I could just write at the very top, no biggie.

As for IV's, I'm not allowed to touch them as an extern I so I left it off. When I'm a II we can, then I'll have to include it.

Thanks!

this is my "cheat sheet" that i created for myself and was using while still on my previous unit: neuro/tele. i am new nurse with only 10 months experience but it helped me to accumulate most details and focus on most important staff r/t pt.

sheet I.doc

Don't forget Diagnosis, Doctors, and consults!

I have to color-code. Our hospital has colored cheat sheets. I use them but use high-lighter on room #, name, Dr. & IV column. I write allergies in red and circle them. I circle the room # in red of the DNRs. I take report, labs in black and write MY assessments for MY shift in red. That way I can see at a glance where the pt. was during the prior shift and note any changes from MY assessments. Anything noteworthy, I high-light AND circle in red.

I think I have a form of attention deficit and this works for me. I gave up on using a clip board, I would drop it or leave it in rooms.

Don't forget Diagnosis, Doctors, and consults!

I have to color-code. Our hospital has colored cheat sheets. I use them but use high-lighter on room #, name, Dr. & IV column. I write allergies in red and circle them. I circle the room # in red of the DNRs. I take report, labs in black and write MY assessments for MY shift in red. That way I can see at a glance where the pt. was during the prior shift and note any changes from MY assessments. Anything noteworthy, I high-light AND circle in red.

I think I have a form of attention deficit and this works for me. I gave up on using a clip board, I would drop it or leave it in rooms.

Yeah, forget a clipboard. I quit carrying my extern manual around today because I got tired of losing it 50x every shift.

Week to week we have the same doctors for our patients in different pods on the floor so I'm usually sure of who to get ahold of if need be.

I edited it up a bit and added items that are part of the daily assessment that I can quickly do at bedside. Everything else can be done outside the room at the chart without having to talk to the patient, which SHOULD save me a ton of time.

Today was crazy! One patient with gastroparesis had his vitals go to hell 15 minutes before I got off my shift, we had 2 stat lab orders but no tubes to send them to the lab on my unit or the next unit over, had a patient go #2 all over the floor and himself. Other externs were gone by 3 but I wasn't off the floor until 3:30, or should I say 1530 lol.

I am quickly learning to take everything in stride and give 100% of my attention to the task at hand, or else I don't do it well at all.

I did have a few staff members and patients tell me that I am doing great and have made great advancements in my few days there, that made the end of my shift a little easier.

here's what i use:

report sheet days.doc

i use something similiar to your sonja. i take report in green and anything i add is in blue or black. i highlight as necessary. i only put allergies in red, so i can find them easily. i also use a whole page so that i can make notes as needed. i have a spot for medication times to cross off when i have given them. i also have a spot for orders and what i need to pass on to the next shift.

I used to add to mine if they were a no code (DNR). We occasionally had situations when nurses (including me) who had up to 10 pts on an evening shift (more on nights) couldn't remember who was a code and who wasn't.

Our hospital uses patient stickers that include name, doc, DOB, MR #, date of service (admission date), etc so that's merely a matter of adding it to the section for each patient.

After that I make a special note of meds as to when - 2100, 2200, 2400, 0300, etc and what form (PO, IVP, ATB [iV form, not PO] etc so I can prioritize my rounds and not overlook anything when gathering my meds, since they may be in one of several places depending if they are allowed to keep nasal sprays, for instance, at bedside, or pharm-mixed solutions which can be either in their patient bin in the med room or in the fridge, nevermind what you gather from the Pyxis. I also note insulin, whether sliding scale (SS), Lantus, or both as that is another fridge entirely. Thankfully in the same room as the other.

Other than that pretty much what everyone else has noted for info save that our aides give us sheets with the VS, Accu-Cheks, etc for the patients after each set of rounds. That keeps the cheat sheet less cluttered and also allows me to see at a glance if there are any VS that warrant further investigation.

Ayrman

You guys' organizational skills amaze me. My coworkers must think my brain sheets look like absolute hieroglyphics. They are a complete mess. I usually fold my report sheet into 6 even squares (or 4 if I'm on a telemetry unit) and write all the relevant info free hand at the top--room #, name, age, dx. The middle part of the square includes relevant report in short hand. Then, at the bottom I write down all the tasks for that patient--BGs, dsg changes, meds, IV starts, family to call, orders that need changed, etc. Then, the middle blank part of the paper is for additional information that occurs on my shift. This may not work for anyone else but it makes perfect sense for me!

Modified 10,000 times over, I think I finally have one that works for me!