Forms to organize your shift

It helps to organize the worksheet in a manner that follows the

way you think and work...and use whatever "shorthand" or symbols

that you use. It helps me to just write the abnormals as I assess

a patient...and that way I know that all else was normal and that

saves me time.

Hi,

I'm in my last semester of nursing school and would like to draw up some paperwork I can use to organize my day. I've read that some of you call this your nursing "brain", does it have any other common names? (I wanted to download one from google but can't describe it well).

Does anyone have other documents they use periodically or regularly besides their "brain"? I'm thinking I'd like to make a special one for some special patients (i.e. a special neuro shift organizer with neuro reminders).

Even better, does anyone have an electronic copy of their forms they can email me?

Thanks so much for your time and help!

My "brain" may vary from your "brain." Depends what you consider important data. I made a form on word.doc. Use abbrev or symbols that you're comfortable with so that you can just circle rather than writing it every time. You can make columns / table to fit what ever your assignment (eg number of patients). You will keep streamlining your form until you find the "right fit" for your "brain."

My "brain" includes:

Room #, pt name, age/M/F, diagnosis (MD name if needed).

Diet NPO TF (eg NG, GT, JT) Act

VS + Pain level.

Treatments: NG - suction, drains (eg Hemovac, JP, penrose)

Dressings (eg DSD, W - D, wound vac)

IVs

Meds (you could write out the times of your shift, then circle as needed).

[Example: 07 08 09 10 11 12 13 14 15]

Tests [for your shift] (eg lab, x-rays, PT/ OT, etc)

Comments (eg important info to remember or pass on to next shift)

I design my own report sheets that include the following:

Name, age, code status, Neuro, Respiratory, Cardiovascular (BP, HT etc), GI, GU, Pain, Drugs (drips etc), Labs. That way I don't forget anything and I get in some good habits.

try typing "brainsheets"

i got great examples that way

we use kardexes and hand them off to the next shift, I try to write on the second page info i need and then put correct info neatly in spaces to update the kardex daily. Usually i attach the front sheet of the Kardex (has all the systems, docs, doc phone numbers, dx,hx etc accucheck y/n, etc with the newest one on top. I tried every brain sheet i found online and went back to the kardex and a paper divided into 4 sections with a label for each patient (usually 4, its an IMCU/tele floor) on the top of my 5 ring binder with stuff i need to do and give to next shift, vitals, last bs and coverage, and i put a little box next to the things i have to do and check off as i go..top sheet works for me because when i go in the patients room to introduce myself, write on the dry erase board my name, phone ext. and other stuff when the pt tells me he needs pain meds or blanket, whatever i jot it down and collect all stuff for when i go in to do vitals meds etc.

Everyone at work uses a 5 ring binder from www.carstens.com and puts their info in there to keep private with dividers for each room

hope this helps, i am almost at a year and it takes a long time to give a good report and sometimes you just don't have all the answers for the next nurse, it gets better

good luck