daily nursing care sheets.. help!

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Hi!

I am a new nursing student working on a general med/surg. floor I and have been struggling to develop a care sheet that will help me follow and keep track of the patients on my assignment each day. When I say care sheet, I am talking about a way to organize each of the patients daily meds, ADL's, diet etc. Any ideas would be very helpful!

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Specializes in Trauma, Teaching.

There've been several threads where people described their sheets. This is one I posted a while ago for someone else:

I used to use a grid, with hours across the top, and room numbers down the side.

I'd put last name & dx below the room number. Under each hour, I put in meds due for that hour, by route so I'd know how long it would take me, when VS were due, dressings or procedures, anything I would need to do for that person. If there wasn't a specific time something needed to be done, I'd assign myself a time to do it, so that I could balance getting things done. (ie, room 8 dressing change between 9 & 10, room 9's after 10 because his doc made rounds late). Then I would cross off things as I did them. If I didn't have time to chart, it would also give me space to make a quick note to myself (type of drainage etc.), and a time reference for entering it in the chart later.

I made them on the computer and kept them in my locker, with "VS" typed in at the standard times, or B/B for bed and bath, etc., then write in specifics after report. After a while, other people were borrowing my template and making copies for themselves. Now I work in the ER, and such planning isn't possible anymore!

Good luck!:balloons:

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Specializes in Ortho, Neuro, Detox, Tele.

I have one divided into 2 halves.....top right quarter is for 8PM vitals....

top left is for CPMs, Ice, Onetouches, feeders, turners, baths, and incont people.

bottom right is for 11pm vitals.....bottom left is for I/O, and anything misc stuff....

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Specializes in healthcare12 years.

if you give me your email I can email you my worksheet

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Thanks for the comments :)

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Specializes in Open Heart/ Trauma/ Sx Stepdown/ Tele.

For the medications if you receive a computer print out you can go through and highlight in different colors the times. ie yellow for 0730 and 0900. Pink for 1130, 1300. Green for 1700, 1800 and 1900. Also we receive a computer prontout that we call a rounds report...has the pt info, allergies, patient care portion, labs..etc. In report I will go down the side and write report. Then on a blank opiece of paper I will write down various bits..ie.....

"Smith"

WT____ ......................#22 LFA 7/7 ...........................................................bs 0730____

...................................Dopamine 1mcg:4.2ml/hr ................................................1130____

EKG____........................................................................................................ 1630____

2d Echo ____

Wound Care____

Incentive Spirometer ____

Cough/Deep Breathing____

BM____

FC_____

...Design it to your patients needs....can also use to write when MD's were in, when pt left floor for teat etc. I then place this in to a three ring binder with dividers with pockets..so every person has the above sheet firts, then rounds, then meds. I also copy orders on the copy machine and place them in the pockets to help keep track of what is giong on as well.

hope this helps a little

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