I take report on my cardex by making the following notations and filling them in as report progresses: :hatparty:
*A&O:, Heart:, Lungs:, O2:, IV:, IVF:, PPP:, Ed (edema):, BS (bowels sounds, last BM, abd soft/firm/whatever):, F/C (or voids):, Accu (accuchecks ac/hs, q4h, whatever):, Skin (includes dressings, rashes, etc):.
*I write notes out to the side re: reason for admission, recent findings, etc.
*I then have a paper worksheet which I made on Works Spreadsheet, that has boxes for each pt with name, room #, dr, dx (diagnosis), diet, all of the above categories I used in report, procedures, consents, labs, dressings, call out to dr, chart check, meds, etc. I fill this out after report, and use it as the top sheet of my clipboard all day long. There is an empty space at the bottom of each column and I write in new orders in red, and cross out changed info, such as IV restarts, IVF heplocked, dsg now OTA, etc.
I have been a nurse 20 years and have made out my little "cheat sheet" every day. This helps immensely.
*It also helps to have your own little "shorthand code" when you are taking report. Sometimes I give report to people who write EVERYTHING out long, even "oxygen" for O2!! and I wonder how they ever get anything done!!!
*Also look thru my MARs right after report, write under each pt's name when their meds are due (9,12,1,2,5,6, whatever) and sign my name on each freakin' sheet of the MARs.
*Then I get on the computer and look up each pt's labs. If they're ok, or within a point or two of normal, I just make a mental note of it. If something or everything is off kilter, I print a copy and put it on on my clipboard next to that pt's Kardex, and if it's really weird, then I go immediately and put out a call to the MD,^^ (AND always chart in the nurse's notes or wherever, that you have noted the abnormal lab and that you called the doc and talked to "X" & put down their name of whom you talked to at the office/service, and that you are awaiting return call. Then chart when he called back and what he said, or if he didn't and you called again. This is personal pet peeve of mine but has got me out of some jams when the doc says, "Nobody called me about XYZ")^^.
*Also, doesn't hurt if your Kardex lists all the consulting MDs to write out by their name what their specialty is, if you can find it out. I hate to get an order from dr to "do X if ok with Cardiology" and have to wade through a list of six or eight consultings to figure out which one is which. Of course once you've worked in a place a while you will know off the top of your head who is who, and just have to look up the occasional odd name.
*Basically, it's taking 15 minutes to make a detailed list and follow through with it.
Hope this helps!!!