How do I remember all my patients info during clinical?

[konp]

I have a difficult time remembering all my patients information during clinical. During the medical-surgical rotation, I had to go to the hospital and pick patients and I generally have all the important information regarding how the patients came to the hospital and what were the physicians' plans for them. I had three patients in my last med-surgical rotation and I found myself to have a difficult time remembering the pts' info and I fumbled with my SBAR and lab sheets many times to look for their info when I gave a report to my instructor for each patient. A classmate of mine said that she read off the pts' info from the SBAR page and the instructor seemed to be fine with that. However, another classmate of mine seemed to have all the pts' info memorize by heart and she gave her reports to the instructors without fumbling; I mean she referred back to the lab sheet now and then since she could not memorize the lab values for her patients at time. But when I tried to imitate her, it was close to impossible.

My question is do I have to memorize all the patients' information when I give report to my instructors? OR is that optional?

For working nurses out there, do you generally remember all of your pts' report? if yes, how do you remember the pts' information.

[Sun0408, ASN, RN]

I know why they came to the hospital, what their admitting dx is, what tests they have had and what lab values are of importance.. Not every lab value is important.. A renal pt, I will know their k, when they had HD last and when they are go again etc.. The rest, well I have the report sheet (kept in the chart) as well as my sheet to help me keep everything straight.

Reading off the report sheet is ok, and you will get better at remembering what information on your pt is important to report off and what information is not.. Ask your instructor for tips, ask other nurses and listen to them give report. It is still new to you and it will take some time to feel comfortable. Remember, report is just like a conversation :)

Any events during your shift are helpful to report off, ex : FS of 30, vomiting post abd surgery; MD was notified and he does not want a NG placed.. Pt went into A-fib, pt gets confused at night etc....

[piinkk]

My instructors always taught us to jot things down because you can never remember EVERYTHING. There's just too much to remember and you don't want to risk confusing patients with one another. Stick to whatever you are comfortable with, if you need to refer to your notes go for it.

You'll get the hang of it

[anonymousstudent]

It's a matter of being organized. Make a sheet yourself - everything you'll cover in report. Go by system or by topic or whatever makes sense to YOU. Make an SBAR box on there somewhere. Write down important stuff. You are not a computer, you can't remember everything. What you don't get in report open up the charting and pull it off of there to complete your cheat sheet.

[loriangel14, RN]

There is absolutely nothing wrong with writing it all down and then reading it when you give report.No one expects us to memorize it all.I have been a nurse for six years and I still write most of it down.

[shortnorthstudent]

I print out my SBAR. I fold it in half and use one side for my info. On it I write - assess, vitals, orders, labs and then the times that I have to give meds. I then make note of pertinent information about my patient under those categories. I only not relevant labs - abnorms and sometimes even norms depending on what's going on with my patient.