I need a good patient organization day planner/tool!

nurse_becks6 · Feb 11, 2009

Hi Cincin1~ I have an excel sheet that I worked up on my own for my med surg, pediatrics and orthopedics rotation. I'll be in ICU/CCU next week for my clinicals and will most likely use the same form. If you want me to e-mail it to you I would be more than happy to do that. I'm in fourth and final semester of my ADN program. I'm super organized and routinly get picked on for making up my own floor sheets, at least they keep me on track!...I think I did them all in excel though.

I'll keep checking back to see if you want them sent! Good luck tomorrow. You'll do great.

Nursebecks6

nurse_becks6 · Feb 11, 2009

This thread has answers as well. I guess we all have a little something different when it comes to report sheets. You really just mess around until you figure out what works for you.

https://allnurses.com/general-nursing-discussion/need-end-shift-176730.html

Toodles~

redalert7777 · Oct 25, 2009

Hi Nurse Becks,

I would be interested in seeing your brain too, but can't figure out how to email!

Thanks!

Rebecca

nurse_becks6 · Oct 25, 2009

Hi Rebecca~ Apparently in order to e-mail any users you must have at least 15 posts on allnurses to have that privilege. Since neither one of us have made that goal yet I can post my old school address here (that still works) and go from there.

You can e-mail me through my profile page and I'll send you a copy of my sheet I use at work. When I graduated and got a job I tailored the sheet to the hospital I work for. It's easy to adjust and alter it to fit your needs. This is still one of the most important tools when I'm on the floor, as it has everything I need in my day to day Med Surg position. I hope you can use it as well to aid in organization.

TTFN:up:

Nurse Becks6

VickyRN, MSN, DNP, RN · Oct 25, 2009

Moderator's friendly reminder - Please do not place personal e-mail addy's in posts. This is a violation of the Terms of Service (the rules you agreed upon when joining our nursing community) and also places your privacy at risk.

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Thank you.

vmoh18 · Oct 25, 2009

I have attached a copy of a flow sheet that I got from another member of these forums. It is only for one patient but I will print more than one if I have two or more.

Student Clinical Report Sheet[2].doc

SmilesNoir · Mar 2, 2011

I like this planner

pinkkitty11 · Mar 2, 2011

When I first started I used report sheets from other people, but found that most of the time it was better to make my own-- something that made sense in my brain!

I don't have a formal report sheet, but here is what I do: Get my kardex/patient profile sheet in the morning, and flip it over. I write on the left hand side all the different systems, N, Heart,Resp,GI, GU, Skin. Then on the right hand side I write their name/room number larger in Sharpie, and if they are a DNR I write that on the top and highlight it in purple ( I like colors :) ) then under that, I write "Hx", where I write down why the pt came in, important history points, etc. Then I write down "Rx", and make note of what time (and how many, or a note if it is a complicated medication (TPN or something that will require extra time to set up) I will be giving meds during my shift, as well as PRNs. Seems like the first time you go into a patient's room they want to know what the plan is and when they can get pain medicine. Lol. I also make it a good habit to write down all of the labs that are important, and any that might need to be done, such as Vanco trough, H/H, heparin recheck, etc.

The assessment section I talked about earlier, I use to jot down notes after I listen to my patients, before I am able to sit down to chart. We do have computerized charting and mobile laptops you can bring in to the patient's room to chart, but I always feel like I am distracted by the screen, lol. I recommend that especially when you are starting out that you take time to write EVERYTHING down. because worst case scenario you cross it off your list.

The Rx/PRN section I use to give report to the oncoming nurse as well, and make sure to tell them about anything I may have given. As for working in the ICU, I would recommend under each heading to have a section written out for things such as: vent settings, drips, ECG monitoring/rate, and check off when you are medicating and suctioning.

I hope this helps you get a little more organized! Sorry it is so wordy. Once you spend a little bit of time in the setting it will make more sense what is useful and what doesn't need to be a quick reference.

Nurse Kyles, BSN, RN · Mar 3, 2011

The local hospitals around here have their own report sheet for each unit. I usually take that sheet & make my own that has similar flow. This makes it easier when I am giving report, because that is the order that the nurses are expecting to receive report. The idea of writing everything on the back of the profile sheet is nice, but we cannot take any official papers home from the hospital. Since I need the info I write down on my report sheet for clinical assignments, I find it better to have my own sheet. I use the RN Report Card sometimes too. This is a pocket sized book that has slots for all the info about your patient. It really helps me keep my assessment data organized. Good Luck!