I lost my clipboard full of nursing notes today! :(

Nurses New Nurse

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Specializes in ACNP-BC.

Oh my! I'm on week 7 of my RN orientation, & today was the first day I had 6 patients. It was nutty-one patient was going to the OR, another to the cath lab, and two more to CT. So I'm trying to do all that & prep them & assess them & give meds (if they could get them) before they went down-& then assess & give meds to the others & was getting so many calls from docs, family, etc! Sheesh! but despite all of that, I felt like I was doing pretty well & on top of things as best as I could. Around 1 PM, my preceptor asked is she could do anything & I asked her if she could hang two IV antiobiotics on one of my patients, cuz I had to give meds to two others at the same time. So then after that we looked at a patient's bedsore, checked to see that a wound nurse consult was put in, cleaned her sore, & put on a new dressing. Then I went to lunch (finally!!!) at 1:50-2:20 PM. (my only break) Then after lunch I recheck all the patients who were there, assess the one who came back from the OR, assess the one who came back from the cath lab, count up the Is & Os, hang up some new IVFs that ran out, etc. Then it was 2:55 PM & I went to look for my clipboard to give report on my 6 patients to the next shift. I COULD NOT FIND IT ANYWHERE!!!! Needless to say I started to get really nervous & freaked out. I looked in every patient room I went into, all over the nurses' station, the med room, the break room, the hallways, the pull out tables outside of patient rooms that we write on, everywhere I went-& could not find it! I looked for 10 minutes-my patients must have thought I was nuts cuz I went into their rooms like 50 times in 2 minutes looking for the darn clipboard. So then I'm thinking, ok, I'll just look at the assessment notes I wrote & put in their charts-but all the charts were gone-docs had them & were writing in them, etc! AUGH!!! Meanwhile my preceptor knows I lost it & tried to help me look for it, but then she says I should just try to give report from memory & to just visualize my patients in my mind & that that will help me give report. The only problem with that was that my mind was totally fried by that point from having 6 patients for the first time ever, & trying to do everything on time-I could not even tell you MY middle name if it wasn't on my clipboard at that point! Then another nurse said "Hey-I saw it on the waiting room." Yep-it was mine! But guess what? I was never even in the waiting room! Someone must've walked off with it by mistake & just left it there! That is so not right. It had ALL my assessment notes on it, all the order changes, any pain-SOB complaints they had, the tests they went to, etc....in other words EVERYTHING! So when I got it back (it was 3:15 by this point-I was so behind!) I started to cry a little & of course everyone is looking at me-I couldn

't help it I got so scared thinking how am I supposed to just give a full report on 6 people on my first day having 6 when I can't remember anything right now. But then once I got it back & calmed down a bit-I gave report. Has this happened to anyone else before? So now I'm trying to see if I can remember everything on my patients off the top of my head-& I can remember more than I thought-except I cannot memorize/remember who had clear lung sounds, who had wheezes/diminished sounds; who had edema in their legs & who didn't, the types of IVFs they're all getting, that kind of stuff. I mean how can you with that many patients? So of course I need to write it down to remember. My brain can only hold so much info at one time! Tell me what you all think. But seriously, other than my lost clipboard freaking out episode, I felt like today was not that bad at all. I will just bring in my roller skates for tomorrow to move faster! :)

-Christine

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Specializes in Operating Room.

Congrats on having your first typical nurses' day! lol .....or so I've heard haha

I'm glad things finally calmed down for you. Tomorrow, glue the clip board to your hip! hahaha

....maybe one of those clap-on key finders will work! :chuckle

Good luck, and congratulations on your new RN title! :) I'm hoping to start nursing classes in January....your post sounds terrifying and exciting at the same time! :)

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Specializes in ICUs, Tele, etc..

Hi maybe you should try to get in the habit of making a worksheet for your seven patients in one paper, on a page paper....it's where u can take report and put ur labs on, after awhile you will get used to your technique and would be able to do it in a blank piece of paper, in a consistent manner. Working with just one piece of paper that's folded and in ur pocket is so much more efficient because you have access to them anywhere you go, and it's better when you do need to speak to a physician or other medical personnel because everything is right in front of you. Yes your paper would be full by the end of the day but at least you know it will always be in your pocket available to be your resource aat. this will help you also to write in ''nursing'' hand, all the pertinent info in a very small piece of paper.

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Chris :icon_hug:

It sounds like you've had a busy day. I've been in nursing for 13 years and I still use a "cheat sheet." I do find though that because I write info down, I remember it better and organize my care better. It stays in my pocket. I could give report without my cheat sheet, however when I first started I would have need it for report. In time you will be able to do this. Right now you are learning so many new things right now along with caring for patients, which is a difficult time for any new nurse.

It does sound like you stayed like you stayed on top of everything where your patient care was concerned. :yelclap: :yelclap: :yelclap:

I wonder if your reaction to losing your clipboard had more to do with the stress all new nurses go through. It will get better.

If worse comes to worse and you lose your clipboard again, you can always refer to your charting/assessments.

All the best to you Chris

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Specializes in Med/Surg, Ortho.

Yep,, sounds like things that happen to me sometimes..

I walk around sometimes asking if anyone has seen my brains. They eventually turn up.

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One reason to not have a clipboard, only a folded piece of paper that stays in your pocket. There should not be that much info written down that it requires a clipboard. Design a sheet that gives you space to put the info that you need for a patient, and on the backside of it you can write any new tidbits to chart later on. And the sheet should hold six patients, not one sheet for each.

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I have a habit of taking out my sheets to chart and I jote notes on my sheet. I forget to pick them up and then I spend about five minutes looking for them. :)

When someone finds papers they always ask me first if they are mine. Fortunately there are other forgetfuls and they usually are someone elses. :rotfl:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Hi, Christine! Been there. Had that happen. I always kept my "brains" in my pocket. It just got to be a habit after months and years that I pulled it out and wrote down important things on it. Only assessment information that deviated from normal or the patient's usual condition is what I noted on my "brains". It's safest in my pocket and I have access to it at any time (especially if a doctor shows up with a question for me about one of his patients). I also had a pen stuck in my hair which was pulled up and pinned to the top of my head--made a great pen holder! I kept two extra pens in my pockets because if I didn't the one in my hair would take a walk and disappear at the worst times. :rotfl: A couple of our regular doctors had no problems just taking my pen out of my hair like it was just waiting for them! (Actually, I liked it!)

I also had a clipboard, but the only information I kept on it was stuff like photocopied pages of diabetic and heparin protocols, a guide that I used for writing up physical assessments (20 years ago we did narrative notes, no check off forms), and my own little protocols for chest pain,abdominal pain and what to chart in the patient's narrative notes if I had a code blue. I kept it on my med cart. We usually had our own med carts to work from (or I just commandeered one) and I used mine as a rolling desk. You could always find me by finding my med cart! :loveya:

Joyce

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Specializes in ACNP-BC.

Thank you everyone for all your advice. I'm happy to say I had a much better day today-especially thanks to my preceptor at work. I've been shuffled around with 9 different preceptors & I think the one I had today is in the top 2! :) She REALLY helped me stay on track, helped me see how I should organize things, prioritize, not fall behind, things like that. I walked away actually smiling at the end of the day! :) Woo-hoo! Even though I had 6 patients once again! :) She let me know I was very attentive to my patients, and very thorough & careful & commented how it was good that I looked up all unknown meds before giving them & also that I never do something I don't know without asking for help first. So then we both agreed that I pretty much just need to focus on my time management skills! :) I took her advice & changed a few things around & noticed the difference today already. I'm working with her again this weekend, so I'm happy about that. It is so nice to actually work with the same preceptor for more than one time-what a concept! I think I really needed some structure & guidance, cuz honestly, the other "preceptors" I've had were all very nice but really did not guide me much at all. So I'm happy I had the one I had today-I feel so much better just in one day-cuz it never dawned on me to do things the way she suggested.

-Christine

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Specializes in Operating Room.

I'm so happy to know your day was better today!!!! Thanks for updating us! :icon_hug:

Any organization tips to share? :rolleyes:

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Specializes in ACNP-BC.
I'm so happy to know your day was better today!!!! Thanks for updating us! :icon_hug:

Any organization tips to share? :rolleyes:

One example of a tip I got today was as soon as I got report from the night shift nurses, to then look at my patients' med sheets right away & if they had 8 AM meds to give for example, to write an 8 with a box next to it on my little "cheat sheet" & once I give the 8 AM meds, to check off the box-so I would know I'm done.And if they had 11 AM meds to give, then write "11" with a box next to it on my sheet, etc. But this way, I wouldn't have to keep checking the med sheets 50 times per hour to see if I still had more meds to give the next hour-it just saves time. (and if there are changes to the meds from the docs during the shift, the charge nurse lets us know them always)

My preceptor also suggested I use legal abbreviations when I write my assessments-cuz I was still writing out things like "alert and oriented to person, place, and time" instead of just writing "A & O x 3" which can also save me some time. And after I write my assessments in the charts, I 'd also write a summary of my assessment on my cheat sheet so I'd have it for report & so I could keep track of any changes from there-but I'd be almost re-writing the whole assessment again on my cheat sheet! So my preceptor said to just write the major points down-anything abnormal & boy did that save me some time!

Hope that can help another new nurse too! :)

-Christine

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One reason to not have a clipboard, only a folded piece of paper that stays in your pocket. There should not be that much info written down that it requires a clipboard. Design a sheet that gives you space to put the info that you need for a patient, and on the backside of it you can write any new tidbits to chart later on. And the sheet should hold six patients, not one sheet for each.

I always use the one sheet of paper, but I keep it on my clip board. I tried just to fold the sheet up and put it in my pocket, but it was easier to loose than the clip board because I needed to take it out to write vitals etc. on it and I would lay it down and loose it.....so to make a long story short.... I always keep it on my clip board now. but that is my 2cents.

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