Any hints on organizing patient info?

Nurses New Nurse

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Hi all! I've been in orientation for two weeks now and just yesterday worked on the floor for the first time with my preceptor. The first thing we did was pick up the paperwork on each patient and look up labs/meds/ treatments. She told me I would develop my own system for how to organize my paperwork, what to write down and where. I would love to hear from any and all of you specifics about how you organize this info. Please describe in as great detail as you can: "I draw a line and list these things on this side ..." I am interested in learning about what systems people have created for themselves that help keep info recorded in a standardized fashion. Thanks!

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Specializes in Acute Care, CM, School Nursing.

I am constantly on the lookout for a better report sheet. So if anyone has a good one, please let me know!

At my job, we have "pencil cardexes" on each patient. When I come in, I copy down all the important stuff from that, before getting report. This way, I'm not rushing to write everything down in report, since I already have some on my sheet. I usually just use a blank page to do this, because I haven't found a good report sheet to use yet. I'm not crazy about the one my hospital uses.

I am also a huge fan of the checklist. Along the right side of each patient section on my paper, I write down important things to be done, such as check labs, write notes, dressing changes, calls to make, etc. Then I draw a little box, to check off as things are completed. I don't know why, but checking off all my little boxes makes me feel like I'm accomplishing things. It's so easy to forget things during a busy shift, so my boxes make me feel better. LOL

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Specializes in Emergency.

Here's the sheet I use. I'm an oncology nurse, so it's tailored to the info I need, you would, of course, want to tweak it to your needs.

I filled in the first column with the stuff I usually put into it. Also things that go there are code status and/or isolation. If they're DNR, their name gets highlighted. Isolation gets the type (using the initial), written in red & circled, also with the location & bug.

Next is chief complaint on admit, pertinent things that have happened in the last few days, any other services that are following, etc. Then the hx line if for pertinent history.

As for labs, those are the ones I tend to care about the most. If something else is off (K/Mg/whatever), I'll write it in. Also if they're accu-checks, I'll write this in here.

For the meds/IVF section. The top is for the type of access they have, followed by maintenance fluids, and then PCA if they have one. If they have TF going, it goes here as well. The second half of this column is scheduled meds & what time they're scheduled for. If I have room, I'll also write in any PRN meds they've been using.

The orders column is pretty self explanatory, wherein DW=daily weight. If they need a weight, that gets circled.

The last column is mostly to make sure I get all my charting & other tasks done. If their IV/dressing change/needle re-access/tubing change is due the next morning, this is where I'll make a notation of it. If there are any labs (urine, etc.) that we need, I write it in here; as well as whatever bloodwork I might be drawing in the morning. I make a notation of how their vitals are when I come on, in addition to the frequency of their VS.

It looks overwhelming to some, but it really helps keep me organized throughout the night and makes report really easy. I pretty much just read left to right when giving report. Any pieces of my assessment that are worth passing on, I usually write on the leftmost portion of the page, in green. This helps me to remember to mention it, as well as serving a reminder when I'm charting. B/c sometimes the time of my assessment and when I chart it can be off by hours, depending on how busy the floor it. On the rightmost part of the page, anything that happens during the night or PRN meds or things to address with the MD get written in red.

Whew!

reportsheet.doc

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Thanx msjellybean,

Your report sheet has inspired my report sheet. I'm using it as a template to reorganize it for rehab nursing. Thanx alot!

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Specializes in Utilization Management; Case Management.

Ur sheet is sexy! If I may say so, lol. No job yet for me but I just had an interview, 1st one...but once I get a position this will help sooo much!

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Here is the sheet I used for clinical. I am a psych nurse now so this won't apply for me now. I put it front to back so it was good for four patients. See if you like it and you can change it by configuring it to your needs.

Brainsheet.doc

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Specializes in Utilization Management; Case Management.

Mommycakers...ur sheet is also sexy!

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Thank you all for such such great info! The sheets you supplied will be very helpful to me!

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Mommycakes,

I don't know why, but it won't let me open your file...says it's corrupt?? Is anyone else having this issue? Thanks!!

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Thanx msjellybean,

Your report sheet has inspired my report sheet. I'm using it as a template to reorganize it for rehab nursing. Thanx alot!

Can you forward a copy of what you came up with for rehab nursing? I am a new LVN and I am going into detox and rehab nursing. I'd appreciate it.

Thank you

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Mommycakes,

I don't know why, but it won't let me open your file...says it's corrupt?? Is anyone else having this issue? Thanks!!

Nope, all fine here!

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Mommycakes,

I don't know why, but it won't let me open your file...says it's corrupt?? Is anyone else having this issue? Thanks!!

I use a MAC but it is in a Microsoft word 97- 2004 .doc file. I have a Microsoft Office program for my MAC. Sorry you are having trouble. My sheet is a combination of different sheets I found so I couldn't even tell you were I originally got them from. I then altered it to suit my needs.

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