How to stay organized?

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I am about to start my first RN job on a med/surg floor. While we were in nursing school, I used one sheet of paper in my scrub pocket to keep up with labs, tests, chief complaint, hx, info off the kardex, etc. It was laid out "OK" but could get "Messy" as the day went by...Esp for a complicated patient. I generally had two patients. It was shredded at the end of the day and the only info was last number of the room and bed number (like room 538 bed 1 would be 8-1).

Well, I am looking to see what works for experienced nurses. Do you use a small notebook, a sheet of paper each day or something different? Is there a specific layout that you find works best for you? Do you use one color ink to start the day then use another color for changes as the day goes on? Am I making this complicated?  I was thinking a time table on one side (in case I need to do certain things at certain times) and six blocks on the opposite side to keep up with patient information since I will usually have 6 patients (after 12 weeks with a preceptor). The hospital is completely electronic with a pretty nice system that tells you when do do assessments, meds, etc. There are also bedside med scanners.

So, would you please share what works for you and what you recommend?

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Specializes in Telemetry, IMCU, s/p Open Heart surgery.

I have one piece of paper that I fold into how ever many patients I'll ahve that evening. (If iI have 4 patients, the paper gets folder into 4 sections, etc).

I put a patient sticker on each section and there i take my report. Chief complaint, assessment, MDs, etc. On the right margin I draw a line and make a separate section. This is my pending section. Here I write down things that need to be done. Here i write down if the pt is to be going for a procedure, if they need an IV, labs that need to be drawn, etc.

I dont like the different colored ink or highlighters... I think it's a waste of time to be changing pens and stuff. lol. this works for me... everyone has their own way. it took me a year and a half to develop this method of organization.

Good luck!

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Specializes in LTC, med-surg..

The above sounds really good. I like to use my highlighters, though. I'm a little obsessed with color coding things and keeping them neat and tidy.

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Specializes in Cardiac.

A good topic, one year in and I'm still discovering what works. So far, I find folding my paper into the number of patients I have and making notes, is quite helpful. I also print out a hand-off report sheet from our chartiing system-to verify meds and check labs. I am still working out a system but I know for sure, chart as you go along---I assure you the worst things happen at the end of the shift (discharges, codes, admissions, miserable oncoming shift nurse, patient sent off floor for procedure, miserable family member(s) seeking to drive you crazy by asking for water every 2 minutes and change of lines---you'll be surprised). Keep your charting up to date.

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Thank you so much for the input! I am excited but nervous and know it will take time to develop a system. Folding the paper to make the sections sounds good and making a margin for pending sounds good, too. I am not into a lot of different pens but thought about doing blue for when I get report and using black the rest of the day.

Thanks again!

PS...I agree with charting. Learned in clinical because there was one girl who NEVER charted until the end of the day and always made us late leaving the floor because something would go wrong.

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Specializes in Sub Acute Rehab/ Oncology Med-Surg.

It took me one year to place my organization together. I work in sub-acute rehab, I get a census sheet at the beginning of my shift with pt's info, so that saves me time. I have a good memory, so much of the stuff I remember, but vitals and labs are something I need to write down cause numbers become a different language in my head if I try to remember them!

I am a color-coding queen! Green is antibiotics, red is complains during previous shift or things to be followed-up with, blue is oxygen/neb txs, black is pending labs or IVs. Then a little box for my vital signs and any new orders obtained. It works for me, took a while to place it all together.

Good luck!! :)

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I use a sheet that I made up using Excel. It is pretty specific to post-op patients, but you could add or remove sections according to your specialty. I also use highlighters to flag stuff that I want to stand out on the page, such as what time a foley needs removed, or a patient's next PTT for a heparin protocol. And when I used to work daylight and there were new orders coming in all day, I would write the new orders down in red ink keep the printout in my order slot until the end of my shift. I couldn't stand to carry 50 extra pieces of paper like some nurses I get report from. Just getting report from them makes me frazzled. When I was a new grad, I had a preceptor who was extremely organized and I still use alot of the tips she gave me.

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Specializes in ICU and EMS.

I'm a new grad in an ICU, and have developed this report sheet over the past several months. Certainly in a med/surg setting, you won't need vent settings and drip rates, but you can modify it to your needs.

Report Sheet (1).doc

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EMSnut45 said:
I'm a new grad in an ICU, and have developed this report sheet over the past several months. Certainly in a med/surg setting, you won't need vent settings and drip rates, but you can modify it to your needs.

Thank you so much for sharing your sheet! :yeah:

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I wanted to take a minute to thank everyone for sharing. I know it will take a while to get my own system together, but your tips are giving me stuff to think about. 

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