Experineced nurses...you're best organizing tips

cherrybreeze, ADN, RN · May 5, 2009

Not sure if this will help, but here are some of the things I do....

On my actual patient profiles, I put certain information in the same place on all my profiles (ie, lower right hand corner, PRN meds), I make lines to fill in for I&O (oral intake, IV intake, urine output, drain output...so I don't miss if they have a drain), lines for blood sugar with their time, and a line for the insulin amount, etc. These always go in the same place, too. I write the actual time I went into the room to assess, so that all 6 assessments aren't charted for "1600."

I write in red any info that I get in report, I use regular black pens for my own info, so I don't confuse the two. I do know some people that use different colored pens on their profiles for different things (sugars might be blue, VS might be green), but I've never needed to do that.

I make a shift sheet, also, where I put the times all spaced separately. Under each time, if someone has a med due, I put the room number and what type (ie, 1200: 39 IVP, 41 PO, 46 IVPB). I do the same for sugars (25 BBG, and if they have insulin orders, it's "25 BBG + SS," or "25 BBG + sched"). When I do them, I do the "X" thing...one line means it's done, the other means it's charted. I make separate columns for assessment, IV site obs, checking orders, etc, and put my room numbers underneath, so I don't forget to do or chart those things. For anything extra, I make a list (ie, 25 dressing change, 28 post op, 35 call MD with labs) and cross off the room number when it's done, draw a line through the whole thing when it's charted.

That probably sounds complicated...it's easier since I can picture it in my head :), so I hope it wasn't confusing. I do know that at a glance I know what's done and what's not done, and I leave at night feeling confident that I haven't missed anything.

pagandeva2000, LPN · May 5, 2009

Not sure if this will help, but here are some of the things I do....
On my actual patient profiles, I put certain information in the same place on all my profiles (ie, lower right hand corner, PRN meds), I make lines to fill in for I&O (oral intake, IV intake, urine output, drain output...so I don't miss if they have a drain), lines for blood sugar with their time, and a line for the insulin amount, etc. These always go in the same place, too. I write the actual time I went into the room to assess, so that all 6 assessments aren't charted for "1600."
I write in red any info that I get in report, I use regular black pens for my own info, so I don't confuse the two. I do know some people that use different colored pens on their profiles for different things (sugars might be blue, VS might be green), but I've never needed to do that.
I make a shift sheet, also, where I put the times all spaced separately. Under each time, if someone has a med due, I put the room number and what type (ie, 1200: 39 IVP, 41 PO, 46 IVPB). I do the same for sugars (25 BBG, and if they have insulin orders, it's "25 BBG + SS," or "25 BBG + sched"). When I do them, I do the "X" thing...one line means it's done, the other means it's charted. I make separate columns for assessment, IV site obs, checking orders, etc, and put my room numbers underneath, so I don't forget to do or chart those things. For anything extra, I make a list (ie, 25 dressing change, 28 post op, 35 call MD with labs) and cross off the room number when it's done, draw a line through the whole thing when it's charted.
That probably sounds complicated...it's easier since I can picture it in my head :), so I hope it wasn't confusing. I do know that at a glance I know what's done and what's not done, and I leave at night feeling confident that I haven't missed anything.

Great suggestions, cherrybreeze! I make take some of them myself! :up:

Sometimes, making up your own sheet on Microsoft Word with some of the suggestions mentioned is also helpful. Remember that this is not to be passed in, but a way to keep track of what is happening and a guide to write your notes. You can also purchase those pens that have four colors of ink and a highlighter to help things along as well.

onetiredmomma · May 5, 2009

think about what you want to learn about your assigned pts for the day and outline that on a worksheet sample for your instructors. "google" nurse's brains or nurse's report sheets and you will find tons of report sheets to choose from. try a couple out before you settle on one, or a combination of one. Write down what you get in report and what happens during your day in different color ink so you know what to focus on in report. think about what you want to learn about your assigned pts for the day and outline that on a worksheet sample for your instructors.

hellerd2003, RN · May 6, 2009

I created my own report sheet. I work in ICU, so have only two pts, so each side is for one pt.

I divide the paper into four sections, and fold the paper in those sections, so I can fit it in my pocket.

On the top left, I have room for pt sticker, allergies, categorization/ DNR status, history and reason for coming into the hospital, as well as family dynamics.

In the bottom left, I include sections for neuro, resp, cardio, GI/ GU, skin, accuchecks/ insulin txs, and pt issues.

In the upper right, I put a timeline of my day-- and as I learn my pt, I put all their meds and lab draws at their specific times on that side so I know best where I can time road trips, med issues/ lab draws, etc.

In the bottom right I put a section for abnormal labs, tests to be conducted, any results to follow up on, things to pass on to the next shift.

If I transfer a pt, and am getting a new one, I staple a fresh sheet to the old one, and continue adding sections accordingly.

drew9319 · May 6, 2009

i wish you the best in your future career. i have a sheet that has been used at multiple hospitals. i work in the icu/sdu. we are a combined unit. we can have from 2 icu patients to 3 step down patients. anyway my sheet has the following: its divided into 3rds. top third: pt info, consults, dx/sx, code status, med/surg hx, contact precautions? restraint orders, fall precautions, skin integ, calls to md reason and time, critical lab results, mrsa swab date. middle 3rd: neuro, pain mgt., card/tele, advanced directives, flu/pneumonia vac, med recon,

pulmonary(o2/ett/vent/trach/mode, rate, fio2, peep, ps, tv), radiology stuff, tests and followups. bottom 3rd: gi: tubes and drains, diet/tube feedings, accucheck, gu, dialysis, vascular, ivs(drips, critical drips, iv sites) misc notes. on the back i have the times every hour for the 12 hr shift. in these i time my interventions. meds, accu check, pca checks, bath, lab draws ect. hope this helps you. best case find one that works for you and your situation, then make it for yourself. :up:

RNperdiem, RN · May 6, 2009

Great tips already.

I would add a space to jot down issues to bring up with the doctors when they come around.

This way you cover all non-urgent concerns(some passed on to you from nights) and not forget.

I have so often only remembered what I needed to inform the docs about after they left.

RNKPCE · May 6, 2009

One instructor I had always said " don't wait to do later what you have time to do now" I alway remember that. Because you might be right on task then a rapid response happens to your patient and the best laid plans for the night are screwed up.

I also use a grid. One for my whole assignment. I have the times across the top and the pt room numbers down the left side. I put an "X" for under each time that I have a med for patient across from their name, if I have a fingerstick I write "FS" in the box. I scribble them out when they are given and charted(we chart as we give at the bedside). It is so satisfying seeing all the x's scribbled out at the end of the shift. It also shows me a plan for the night. If every patient has meds at 5p and 6p I know I will be busy then. Or if one patient has meds nearly every hour I know I will be busier with that patient.

Kitty Hawk, ADN, RN · May 6, 2009

Thank you all very much....

Great suggestions. I agree, I will know better as I get my feet "wet" and know more specifics. I understand the assignment is to engage our critical thinking, but I need to have hands on with something like that to best figure it out.

I like the using different inks but I can't find those pens with the colored ink all in one. Are they found at a speciality store, or best to find online?

Thanks again, I really appreciate it.

cherrybreeze, ADN, RN · May 7, 2009

Thank you all very much....
Great suggestions. I agree, I will know better as I get my feet "wet" and know more specifics. I understand the assignment is to engage our critical thinking, but I need to have hands on with something like that to best figure it out.
I like the using different inks but I can't find those pens with the colored ink all in one. Are they found at a speciality store, or best to find online?
Thanks again, I really appreciate it.

I do completely agree that you can only have so much of an idea how to organize your info until you're on the floor with an assignment on a daily basis. I've revised mine several times over the years to better fit my needs, based on experience. Hopefully you'll have a good jumping off point, though.

I've seen those pens in stores (maybe try an office supply store?) or if you're like me, just carry a handful of pens. :) I use the clips to hang on my pockets so they're easy to see and grab.