Help getting organized?

[superdeluxe]

Like many new nurses posting on this board, I'm having trouble organizing the info I get during change of shift and during my shift and also tasks I need to complete. As a result, I end up spending unnecessary time looking for information I probably have written somewhere and also quadruple checking that I've done a task already. And I don't feel like I give report in the most coherent fashion because I'm scrambling to find info in pages of notes. My goal is to get all my info for my 5-7 patients on one double-sided sheet of paper.

Some nurses have offered to send their "brains" or "cheat sheets" to those of us who are struggling with this problem. I wonder if it would be possible to find a place to post these documents (I know we can't use attachments on this site) somehow on this site or somewhere else, so that we can have a resource. That way people won't have to keep e-mail these documents. Any ideas?

And in the meantime, if anyone has a brain they could e-mail, that would help a lot! I have been struggling all morning to come up with one on the computer and can't get a hang of the formatting. Last month I made a checklist of all the forms I need to complete before end of shift on my patients, and it's saved me about thirty minutes work every day.

I'm so thankful for all the help I've gotten from these forums. Whenever I feel overwhelmed about my new career, I turn to the site and am so relieved to find that I'm not alone!

Suz

[christvs, DNP, RN, NP]

Hi Suz, I'm a new RN (been working since July) & I've got a good system that keeps me pretty organized. On my unit we print out computerized kardexes on each patient & when I'm getting report from the previous shift I write down what they tell me & highlight it yellow . Then during my shift, I make notes for myself on the kardex about what's going on with the pt-anything abnormal, labs, tests they had or will have, pt complaints, pain issues, etc. whatever I know I'll need to report to the next shift I highlight in pink. So when I give report, everything I need to tell them is in pink. It makes giving report so easy! Also, during my shift whatever I need to do for my pt, I write it in the margin of my kardex, & when I complete it, I cross it off. That helps me stay organized. I staple all the pt kardexes together and keep them on my clipboard, which goes with me everywhere. This sytem works very well for me & I always feel organized even when the day is crazy (like it was today!!) . Oh & also, at the beginning of my shift, I write down all my pt's med times on my kardex, & as I give the meds, I check off the box next to the time so I know I gave all the meds. I also make a little box and write "assessment" next to it, and as soon as I write & chart my assessment I check off that box. Hope some of this helps you. :)

-Christine

[amy0123, BSN, RN]

The nurses on my floor don't use a clipboard. They use the back of a sheet of paper.

If I was the only one using a clip board, they may look at me as if I'm silly. Maybe not. Maybe it won't be so embarrassing since I'm still new.

The only thing that I am afraid of when using a clipboard is leaving it in my patient's room. Is a clipboard really better than folding the paper for my pocket to keep it out of the way?

I don't have a clipboard at the moment, but I could run over to an office store when I get the chance to pick one up.

[DolphinRN84, MSN, RN, APRN, NP]

christvs said:

Hi Suz, I'm a new RN (been working since July) & I've got a good system that keeps me pretty organized. On my unit we print out computerized kardexes on each patient & when I'm getting report from the previous shift I write down what they tell me & highlight it yellow . Then during my shift, I make notes for myself on the kardex about what's going on with the pt-anything abnormal, labs, tests they had or will have, pt complaints, pain issues, etc. whatever I know I'll need to report to the next shift I highlight in pink. So when I give report, everything I need to tell them is in pink. It makes giving report so easy! Also, during my shift whatever I need to do for my pt, I write it in the margin of my kardex, & when I complete it, I cross it off. That helps me stay organized. I staple all the pt kardexes together and keep them on my clipboard, which goes with me everywhere. This sytem works very well for me & I always feel organized even when the day is crazy (like it was today!!) . Oh & also, at the beginning of my shift, I write down all my pt's med times on my kardex, & as I give the meds, I check off the box next to the time so I know I gave all the meds. I also make a little box and write "assessment" next to it, and as soon as I write & chart my assessment I check off that box. Hope some of this helps you. ?

-Christine

Great advice! This is my second week of orientation and I'm actually trying to do that ? Except the clipboard. I just fold the paper and keep it in my pocket. Thanks for your wonderful advice!

[Ruby Vee, BSN]

amy0123 said:

The nurses on my floor don't use a clipboard. They use the back of a sheet of paper.

If I was the only one using a clip board, they may look at me as if I'm silly. Maybe not. Maybe it won't be so embarrassing since I'm still new.

The only thing that I am afraid of when using a clipboard is leaving it in my patient's room. Is a clipboard really better than folding the paper for my pocket to keep it out of the way?

I don't have a clipboard at the moment, but I could run over to an office store when I get the chance to pick one up.

A clip board is nice, but you can get along without one. If no one else on your shift carries one, you probably won't want to, either. Believe it or not, these silly little things count in terms of becoming one of the group or not. If everyone else keeps their notes folded up in their pocket, do the same. You can be just as organized that way!

[ashley_michelle]

I don't really thing that using or not using a clipboard will have anything to do with you 'being in a group.' People do all sorts of different things on the floor that I work on... it's just whatever is best for you. Some use clipboards... some use one sheet of paper.. some use notebooks ( 3 ring binders ) .. just whatever makes you feel more comfortable. Using a 3 ring binder helps if you want to keep certain numbers ( materials, different units, PAR, etc) so you can get to them quick without searching at the front desk for them. Also, you can keep reminders in there.. policy's or things that you keep getting stuck on.

So really, who cares what you use.. as long as it works for YOU. I keep all of my kardex on hand.. and have highlighted sections. (meds, new orders, diets, activity, MIVF, etc) and then I use a cover sheet to make a check list for each patient for the night. .. meds and times, any flushes or boluses, prn meds, fingersticks,dressing changes.. just the things I HAVE to do that night. It works well enough for me. And as far as reports... we record ours and I just pretty much read my full assessment and add prn's , mivf and vital sign ranges for the shift.

Another perc for a 1/2'' binder ... you can get a little zip pocket of some sort to put highlighters/pens/scissors/alcohol pads.. etc.. so you're not always scrambling in your pockets for stuff. And of course you can add pictures to the front so everyone gets to see a little of the personal/home life. Everyone likes looking at pictures. =) Just don't worry about what the other nurses are doing.. just as long as you keep organized..

[RNKay31]

I too have this problem and it is so stresssful

[Indy, LPN, LVN]

Ashley, I really like your idea for a binder. We keep our MAR's and nurse notes in a binder already. Usually it's kept at the desk. Before I became a clipboard woman, I would use the binder as a tray when I had a lot of stuff to carry to the room. (snack, evening meds, cup of juice, IVF, tubing, whatever else one can cram on a very small tray) Never in my wildest dreams did I think of sticking my own zipper pocket in there, or taping my report sheet to the front. But it does sound kinda neat. You get stuck in a room, voila, you open up and do some charting. Unexpected question from patient about opposite shift's meds, open up and answer it, or at least figure out what they're talking about. Very neat.

[crb613, BSN, RN]

I use a clipboard to keep my nsg notes on (we chart by hand). As I do my initial assessment I chart right then there. When I am through seeing all my pts my charting is done. Then all I have to do is add to it as needed throught the night. I see a lot of nurses that don't even start to chart until 0200-0300....this would drive me nuts!

I have a brain sheet I keep in my pocket w/pts name,age,dnr status,admit date,room #, doctor, dx, hx ( brief) allergies, tubes, drains, lines, tx, labs, tests, sx, diet, iv sites, fluids, pca, dsg, nebs, vs w/o2 sats, accu cks, activity, on it. I have a note section at the end for things need to be done/passed on. If I need to know something through my shift I look at it & update as I go, then I give report from this. We do report face to face...I usually make a copy of my sheet & give it to the next person. This helps speed up report & keeps things from getting left out.

I look at my MAR as soon as I get report to see how heavy they are!(ours are paper & kept in a binder in the med room). I also keep a current vitals list w/my MARS. I go in at 1900 so those meds are already done...I check just in case. Then at 2100 I give my 2000, 2100, & 2200 meds & do anything else scheduled in that time frame, chart if needed. At 0000 I do the 2300, 0000, 0100 meds, chart. I do this all through the night & it keeps me on schedule & allows a little time for the unexpected things that happen. There have been a couple of days when... I could have cloned my self & that would not even have helped!:rotfl: but for most days it works great!

BTW...when I pull my meds I do them all at once...I put each pts meds w/MAR in a zip lock bag & label it. I don't open the meds until I am in the room & use the MAR to double check the med, pt & tell them what they are getting. This saves me a lot of steps!

[rainy scarlett]

Here is mine. It is a combination of a couple that different nurses that shared with me. good luck!

REPORT SHEET (1).doc

[JentheRN05, RN]

Here's my report sheet. I've had numerous compliments on it.

Report sheet (2).doc

[truern]

We print out "onlines" for each patient...they contain name, room #, age, diagnosis, doctor, consults, orders, etc. I highlight pertinent information in yellow. Then during report I add whatever the reporting nurse tells me...for example: location of IVs, A&O, whether or not consents/pre-procedure checklists have been done, last time pain meds were given, abx hanging, etc. Times for meds and accuchecks I write in green (for "GO do") on the left of the sheet. As I give meds, cover BGs, etc I check off the times. Things that happen during the day that I want to report to the oncoming shift I write in red. History, reason of admission, etc I write at the top of the page. I also print out current labs and staple them to the onlines.

Oh, and I use a clipboard. I'm not trying to be one of the crowd, I'm trying to remember what I need in order to give the best patient care. I've noticed that nurses on my unit do what works best for them...and a lot of them use clipboards, too.