Keeping organized

I have a cheat sheet with spaces for report, notes, to do list, vitals, bloodsugars ect... After report, I try to get all the vitals and tx's done and then start my med pass. I make any notes for charting on my cheat sheet. You can search this site for good sheets or create your own.

I use a "nurse's note" sheet when taking report so it can be as messy or as neat as I need it to be. I save my patient census for my own notes during my shift. After report I do quick walking rounds to make sure everyone is okay and to make sure the offgoing nurse didn't miss anything pertinent.

After report the first thing I do is check my PEG residents to see if I'm going to have to get new bags. I set up and prime the new bags and have them hanging and ready as my first task. Next, I take care of any quick phone calls or faxes that have to be done as per report. I'd rather order any missing meds or follow up on anything important NOW while it's fresh in my mind and I'm not caught up in anything else.

After these first tasks I start my accuchecks. In my facility, Medicare patients require skilled charting daily, plus one or two other patients every day (they are cycled through each week) so if any of these patients are also blood sugars, I do them AFTER my regular blood sugars because they will need a full set of VS. I use my census sheet to write down all my BS, BP and VS so that I don't have to chart anything right away.

Once that's done, I do the full med pass for those patients I did my BS/VS on already. After that, I hit the rest of my first med pass depending on the residents and their needs. If a resident has respiratory treatments or skin tear dressings or anything of the sort, I take it out when I draw up their meds, and place it on my cart. If it's a respiratory treatment and I can do it now, then I take it with me. Otherwise (let's say they are eating dinner now) I'll star them on my census sheet and get back to them later. I complete my first med pass this way. When my med pass is complete, I make sure I revisit all of my "starred" patients.

After this I sit down to chart, read notes, make calls, etc. I also take my lunch break around this time to re-charge and get ready for the second half of shift. Usually after charting, etc. and taking my break, it is about 7pm (I work 3-11) so it is too early to start my night med pass. What I do at that point is double check my cart for any needed supplies, double check that all treatments are done, and sometimes (on a slow day) make sure I don't have any medications that need re-ordering. Otherwise, I may draw up meds for a couple of patients that take their meds early or combine their med passes. I take care of who I can before I have to do another accu check and then start the process all over.

That's pretty much it. It's hard work but I rarely leave late and my day goes by very fast!