Homemade forms to manage you patients

Roseyposey · Jul 20, 2007

I am very interested to see if anyone has a form they would share. I have tried a couple, but so far haven't found one that works well for me. I don't want to reinvent the wheel if someone has a good system already made up.

Diary/Dairy, RN · Jul 20, 2007

I use 2 forms, depending when if I am in med-surg or ICU. I like to have more details when I am working in ICU.

My ICU form has 2 columns. I do a review of systems in one - N, R, CV, GI, GU, for Neuro, Resp. Cardiovascular, Gastrointestinal, and Genitourinary. The second column has spaces for IVs, Gtts, Mobility, History. Along the side I place a timeline so I can note when my meds, dressing changes, and other stuff to do at.

AS for med-surg, my current form has 12 columns ( the hospital preprints the form) and the columns are divided as noted: 1 for VS, Intake and Output, O2, Blood sugars, Mobility, PCA/Pain management, 2 for Fluid and IVs and the last 4 for Wounds/dressing changes, incisions, etc.

Sorry I cannot post my forms....

Good organization is the key to staying on top of things!!!

Also, I borrowed these general concepts from my mom and April....and modified them a bit for myself. Hope that helps a bit!

jessi1106, BSN, RN · Jul 21, 2007

I think you probably will need to customize any form to what works best for you. I am a very new nurse...so I need lots of space to list my meds and times, cuz I have to look them all up. I put one line (half an x) through the med once I know its safe, and the next line (finish the x) after its been given and charted.

I also list all of the impt. things that I need to report to next shift in a separate space...so things like unusual chemsticks, d/c plans, NPO status changes etc.

I also list all med allergies, as I am so afraid of making a mistake.

Anyway, I looked at the way others organize and took what I liked from their systems...I have changed mine when needed as I go...good luck to you.

Diary/Dairy, RN · Jul 22, 2007

Excellent point Jessi!!!

I too have to either print out a medication form to remind myself when to do meds, OR place detailed notes for myself on my sheet to remember this myself.

Then again, I have to write EVERYTHING down, otherwise I forget to tell the day shift what's going on!

pagandeva2000, LPN · Jul 24, 2007

I have been doing such a thing, but can't post it. It is not a big secret, but I don't know how to post it. What I think you should do is first see what is usually required and then create a form on Microsoft word or such so that it is custom made for you.

For example, I am an LPN in a clinic. We have to interview all new patients and sort of check off what we taught them, vaccinations given and such. We do have computerized charting, but, many times the volume is so large that I don't have time to go through all of the questions or have time to chart right afterwards. I made a form where I place the chart number of the client on top, the basic questions, meds administered, etc and when I get a chance later, I chart on those and throw the form away. Made my life easier. I am now in the process of creating a notebook of the most common things I have to teach, so that I will always have copies of the teaching material that is easiest for me. I have started accumulating teaching material on diabetes, hypertension, different endocrine disorders, websites and such. This will be an ongoing one. We don't have enough teaching material and our population consists of the poor and uninsured. I try to supply information that is not too complicated to comprehend.

It may take time, but I think you have to see where the need is first and then create your form, leaving room for adjustments. Good luck!