Does anyone use a little laptop/notebook for clinical prep at clinical location?

[TimiT]

My hand is killing me from all the writing & writing so fast at clinicals! On prep day, we pull the patient's chart up on the computer at the clinical location & hand write a zillion things as quickly as possible, including all their meds (which are often 20+) & labs, pt. Hx, physician notes, orders, diagnoses, etc. I was thinking it'd be SO much faster & easier to have a little notebook (electronic) that I can type all that information into instead of trying to get it all written down.

Does anyone do that or have some tips?

Thanks!

[mspontiac]

We used to be able to use our laptops but then they put a stop to it this semester. I'm not sure if it was the hospital or the school that made the decision. It certainly saved a lot of time because we just have to go home and re-type all of the info we write at pickup; it was nice to be able to type it as we gathered the info. I understand why they stopped the practice, but it added a lot of work to an already looooong evening of paperwork prior to clinical day.

[Cyan8181]

I use a netbook at the hospital my school is affiliated with, but not on the floor. If I'm taking info from the (computerized) chart in the library or another non-patient care area, I'll use it. If I am on the floor or at another clinical site, then it's pen and paper.

[coast2coast]

do you HAVE to do all that writing? it seems like a waste of time! could you just shorthand a brief hx (1 or 2 lines) and look up meds as needed?

[TimiT]

No we actually have to write it all out! My hand cramps up & it takes forever. This is all the info we have to hand write, as well as all meds & abnormal labs and it doesn't look like much, but this is condensed - filling it in would require a ton more space of course.

Patient Care Information Student Name:

Patient Initials ______ Last 2 digits of Rm #______ Age______ Gender____ Date of Adm________ DM__________

Code Status___________ Pt's Language_____________ Ht______ Wt_______ Allergies___________________________

Chief Complaint_______________________________

Family Unit________ Orem Health System WC____ PC____ SE____ Pain status (past 24hr)___________

Adm VS_______________ Latest VS ___________________________________

Diagnosis/Pathophysiology/Clinical Manifestations (Underline S/S that your pt has experienced):

Current Surgery (Include date of surgery)

Past medical HX, Past Surgical Hx, Social Hx, Meds PTA

Significant events since admssion

Physician Orders/Interventions/Treatments (Check Active Orders)

VS______ Activity_____________________________ Diet__________________________ I&O _______ CATH _____

POCG:___Y___ N Correction: ___Y if >___ or ___N Last POCG (check in AM) Results: 10p____ 7a_____ Other?_____

Meal time dose of insulin ordered? ____ Y ____N Basal Dose (daily) dose of insulin ordered? ____ Y ___N

C&DB: _____IS: ____ O2: _________O2 Sat: ______Resp Tx: _______________ Anti-embolism devices_____________

Isolation___________ Telemetry_____ IV/saline lock_________ PT ____ OT ____ Speech ____ Assistive Device ______

Drains/Tubes_________________________ Dressings_________________________________________________

Other treatments/procedures ordered:

Review of Systems - as listed within H & P sectionof EMR *Include only the positive findings in history and positive/abnormal findings in physical exam H & P

Constitutional:

Eyes,ears,nose,mouth,throat,pharynx,neck

Cardiovascular

Respiratory/Chest/Thorax

Gastrointestinal

GU/GYN

Musculoskeletal/Extremities/Spine

Integumentary/Skin

Neurological

Psychiatric

Endocrine

Hematological/Lymphology

Other??

Assessment and Plan

Priority Nursing Diagnoses: (List three 3 part statements - Dx...R/T...AEB)

Teaching needs? Please identify

**Submit med sheets, diagnostic sheet with rationales, and care plan/ with this form

[coast2coast]

Oh Jeez. What a PITA for you ! In that case I guess a little netbook might be useful - certainly worth asking your clinical instructor if you could bring one on the floor. It would definitely have to be something that 1. you could risk losing/ruining and 2. wouldn't use at home. You'd also have to give it a good wipe-down at the end of each day but I'd say that's do-able.

[2ndyearstudent, CNA]

That looks approximately like the information I take down every clinical. I only transcribe the meds I am giving and I glance over the ones they get on other shifts.

You sort of get used to it and you get WAY better at taking down only the info you need.

Unless you have a horrible clinical instructor and then you are screwed.

[coast2coast]

That looks approximately like the information I take down every clinical. I only transcribe the meds I am giving and I glance over the ones they get on other shifts.

You sort of get used to it and you get WAY better at taking down only the info you need.

Unless you have a horrible clinical instructor and then you are screwed.

I think she is required to write this all down by her clinical instructor. Ridiculous right? I write 2 to 3 lines about my pt, what meds I need to give, and that's it. Everything else is in the record if I need it ...

[TimiT]

Thank you for your input everyone, I appreciate it! I decided to ask if I can use a digital voice recorder & read aloud (I'm in a private room usually & I of course would not be reading any information aloud that would identify a patient....same precautions as putting info on a piece of paper!).

I am required to write all of that stuff down :) I have to write ALL of the meds they get, whether I pass them or not & am required to fill out a med sheet on all of them :)

I'm good with that....I am here to learn after all!

[ShantheRN, BSN, RN]

We did this for every patient. Do you have to have it done by the end of your clinical day? If not, do it in spurts! It usually took me at least 2 sessions to finish mine because I had serious cramping issues. I wouldn't bring a laptop of any kind because if it goes missing, no one is going to replace it for you.