Staying organized- report sheet for LTC?

Specialties Geriatric

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Specializes in psych, ltc, case management.

Hello again! I just posted a different thread about LTC, but this is a specific subject of it's own so I gave it it's own thread. I'm a new graduate about to start my first job in a LTC/rehab facility. In school I had a one page per pt(back and front) report/assessment sheet I made for myself to follow. It really helped keep me organized, helped me remember what I had to do during a shift, what I needed to know and keep straight. I'm trying to figure out how to make a new sheet for my upcoming job but I dont know what kind of information to include, since it's so different. My old acute care sheet had spaces for me to write down info like: MD, hx, O2, Ivs, foley caths, glucose times needed, VS, meds, neuro checks, procedures, and a full head to toe assessment to check off. I'm sure I don't need half of this on a report/assessment sheet in LTC. What should I include, get rid of, or add? Thanks friends. :)

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Specializes in Geriatrics, Dialysis.

I have been in LTC for 15 years and still use my "cheat sheet" every time, make a functional one and it will be your lifeline! Here are a few things that I find helpful... first make it short and sweet. One page with a list of all residents is preferable so everyone is available at a glance. Simple check off spots for med passes and treatments, most LTC facilities have huge MARS/TARS so I check off on my sheet as tasks are completed so I know I didn't miss anybody. A blank space after your simple check marks for daily notes i.e. who needs vitals this shift, who needs to be charted on, any appointments, changes in condition to track, new orders etc. This blank line can also be used to note any oddball med times so they aren't missed. An area for accuchecks, insulins, carb counts for your diabetics is a must. Especially on a day shift when tracking down a resident to get that blood glucose before they eat can be a challenge...just jot the results on your cheat sheet as you go along and you will save a ton of time. That's pretty much it for the front page, if you try to put too much on there it's difficult to read and stops being a useful tool. On the backside of my paper I have a three simple sections: one to note VS, one to remind myself of any phone calls I need to make/return and one to jot messages to myself as the day goes on. Very useful when you get a Dr call away from your desk and the residents chart, it is easy to note any verbal orders on your cheat sheet and transcribe them when you can get back to your desk. You will want to customize your cheat sheet to the shift you are working, I typically work nights but do work occasional days so I keep a cheat sheet on my computer at work for both shifts as their tasks are much different. Play around with the format until you find what works best for you.

I hope this helps a little, and if you have any questions feel free to email me! And good luck with the job, I hope you find you love it!!

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Specializes in psych, ltc, case management.

That is great thank you!!!

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Report sheets at a LTC I worked at also included primary physician and code status for every patient, as those are things that you sometimes need to know quickly and don't want to have to run find the chart to know whether to start CPR.

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Specializes in Geriatrics, Dialysis.

Hey, what a great idea adding the code status! I think I will do that myself.

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yes I agree with all the posts, do a cheat sheet, you can update it when needed, Our Med cheats also have how the res like his meds to, such as with pudding ect.. my treatment sheet is simple, the accu check and or insulin folks listed, the neb treatments, the dressing changes and licensed treatments-- I write report stuff on the back. --- one paper does it!! ( we have med people (CMA's) to do meds, lucky there I guess.) Good luck!!

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Specializes in Gerontology, Med surg, Home Health.
Hello again! I just posted a different thread about LTC, but this is a specific subject of it's own so I gave it it's own thread. I'm a new graduate about to start my first job in a LTC/rehab facility. In school I had a one page per pt(back and front) report/assessment sheet I made for myself to follow. It really helped keep me organized, helped me remember what I had to do during a shift, what I needed to know and keep straight. I'm trying to figure out how to make a new sheet for my upcoming job but I dont know what kind of information to include, since it's so different. My old acute care sheet had spaces for me to write down info like: MD, hx, O2, Ivs, foley caths, glucose times needed, VS, meds, neuro checks, procedures, and a full head to toe assessment to check off. I'm sure I don't need half of this on a report/assessment sheet in LTC. What should I include, get rid of, or add? Thanks friends. :)

If you're going to work on a short term/rehab unit, you might be needing ALL that information. Our residents have IVs, foleys, neuro checks, procedures and many other things as well.

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If you're going to work on a short term/rehab unit, you might be needing ALL that information. Our residents have IVs, foleys, neuro checks, procedures and many other things as well.

True... what you need on your report sheet will definitely depend on the number and acuity of patients. Always good to ask other nurses in the facility what they use -- they'll have the best suggestions for what is most helpful, most needed.

But I do think that some of the above suggestions should be helpful for giving you different ideas of what other people use.

Good Luck!!:)

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