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Nurse's Notes

Posted

When I had my clinical at the hospital, I carried tons of papers on a clip board or a small note pad, but these are cumbersome, easily disorganized, and could cause cross-contamination. My last clinical period I noticed that a lot of nurses had single pre-made sheet of paper they made notes on. It was good enough to accomandate all their patients. I'm having trouble making mine. I don't know what I should have on it or shouldn't. Or the best way to save space. Or even the program to use. Can anyone help me create my own or post some templates.

chicookie, BSN, RN

Specializes in Peds Hem, Onc, Med/Surg. Has 8 years experience.

ah the nurses "brain"

I fold a sheet of paper twice so I have 4 squares. Each square is for each patient.

I used a tip I saw on here. I write everything like history, name, allergies, etc in pencil. (the things that aren't going to change)Then in pen I write the important stuff like labs that need to be checked, no blood patients, npo. At the bottom of the page I put med times just like 7, 9, 12, 14.

Usually I have one square left over and I use that as a to do list. I use a pencil so I can remove and add stuff.

I would check on here. There was a thread not too long ago call how do you organize your brain that had like templates and other tips.

geocachingRN

Specializes in Community & Mental Health, Sp Ed nursing. Has 3 years experience.

Along with the quad-folded paper, I also use a 4 color pen, Report from nurse and labs, blue; stuff on my shift, black; To do reminder, green; and report hand off notes, red. I got this from my excellent preceptor.

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