Inpatient Psych Brain Sheet

will-b-an-RN · Aug 29, 2012

Hello all, I was wondering what kind of "brain sheets" you typically use in inpatient psych. I am considering making a brain sheet on Excel and was wondering if you have samples of your "brains" to share?

I really need this too, Im a new grad and just got hired in a PRTF. I need to get organized. Please help!

gogirlgo · Aug 31, 2012

What is a brain sheet?

Just curious.....it must be an American thing.

PRNketamine7, BSN, RN · Aug 31, 2012

When I worked in psych we just printed out the unit census and took notes on there.

MrChicagoRN, RN · Sep 1, 2012

What is a brain sheet? Just curious.....it must be an American thing.

I had to look it up. Over 25 years experience and never heard it anywhere else but here.Seems to be a preprinted fill in the blanks report sheet.We have a census sheet with name, age, medical & psych docs, LOS, precautions, password. The rest is an empty space that requires one's own brain to decide what is relevant & needs to be written down.

Meriwhen, ASN, BSN, MSN, RN · Sep 1, 2012

I don't really have a brain sheet. I just make a list of what needs to be done as needed and through the day strike off/add things as necessary.

AtivanIM · Sep 26, 2012

I made a very detailed "brain" sheet and I never use it, I don't have the time! You may find it helpful to make a word doc. with a column for Name/Room #/Diagnosis/MD/ and med times that can be circled.... ex: 0700 0800 0900 1000 for your entire shift.

Plus, it's always helpful to have a spot for PRN meds, especially when you have drug seekers, to remind you it's time to pull the Oxycodone and assess for pain Q4...

Elladora · Oct 14, 2012

I have a sheet I print each shift that has two columns which I then fold down the middle. Column 1 (side 1) has the names of all of the clients that have 1700 meds and column 2 (side 2) has the names of all of the clients that have HS meds. I have roughly 15 blank lines below each list where I jot down notes and such throughout report and throughout the shift. At the bottom of the sheet on side 2 is a list of clients that I am responsible for charting on with a small blank line behind each. I have my own shorthand I use in this area to make notes for charting. (inc - incontinent, incBM - incontinent of BM, hosp - hospitalized, a check mark for anyone on checks, NS if they didn't eat supper, NM17 for didn't take meds at 1700, NMHS for didn't take meds at HS, cream - this is the odd one, anyone that has a prescribed cream we have to administer OR someone that needs wound care, this reminds me to write a skin care assessment when I chart) and prn for anyone that took a prn).

The issue with my sheet? It would make very little sense to anyone else trying to use it. I came up with after months and months of tinkering but it works for me and it works well. I can fold it in half again and stick it in my scrub top pocket and carry it around with me. The blanks are useful to keep track of things I need to follow up on, supplies I need to order, emails I need to send, etc. Each sheet is dated and stuck in a folder in my locker. I can go back and double check something if I need to.

Mandychelle79, ASN, RN · Oct 16, 2012

My brain sheet is basically the sheet I use for my admissions and my 1 to 1 sessions. One nurse passes meds to all the patients on our unit so I dont put meds on it.

Basically my sheet has

Pt Intials ( so I can remember who they are),

Mood, SI/ HI, Affect, Thought Process ( any halluncintaions, racing thoughts, delusions, etc), sleep, appetite, any physical issues and then I have an area where I can put little note ( +si, is there a plan, if so what is it) pretty much it becomes my charting later.