I need help with preclinical paperwork!

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Hi, Guys! I really need help with my preclinical paperwork. We go to preclinical on Monday, when we meet our pt. and look at their chart. We have to look up the primary and secondary DX, lall labs and what the result means for the pt, all drugs we will administer, all medical eq. and lines they are hooked up to (catheters, ostomies, ng tubes, drains, IVs, etc.), procedures they have had recently. My problem is that I get home at 6pm (the hosp. is 90 min. away). The paperwork has to be done by 7am the next morning. I am literally doing this paperwork for 8 hours or more! I need to find a way to complete this in less time (so I can get up at 5 to be at the hospital for 7-and take care of my pt. until 12). I have been looking all of this info up in our books, but there has got to be a better way...on top of this, I have two small children. I need some websites (esp. lab tests and what their results mean) to make this process quicker. I could also use suggestions for the best order to look the info up so I dont have to keep going back and forth. Any help would be greatly appreciated!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you can use this sheet to help you organize what you will do doing your clinical day:

[attach]5444[/attach] (student clinical worksheet)

here is a list of excellent websites where you can look up information about diseases and labwork to get the "low down". the consumer sites, while being easier reader friendly, are really excellent. you can get good information about all kinds of tests including x-rays, ekg, eegs, etc., on medicine net and web md (links below). lab tests online only addresses clinical labwork. you should also bookmark a link to medline plus and it should be one of the first places to look for information. it is loaded with knowledge and links to lots more of it.

for sites aimed more at the consumer (easier to read and understand!):

medline plus (use the search box) http://www.medlineplus.gov/

healthfinder (use the search box) http://www.healthfinder.gov/

medicine net diseases & conditions a to z index http://www.medicinenet.com/diseases_and_conditions/article.htm

medicine net symptoms & signs a to z index http://www.medicinenet.com/symptoms_and_signs/article.htm

medicine net procedures & tests a to z index http://www.medicinenet.com/procedures_and_tests/article.htm

health a to z - diseases and conditions page (use the search box) http://www.healthatoz.com/healthatoz/atoz/common/standard/transform.jsp?requesturi=/healthatoz/atoz/dc/index.jsp

aetna intelihealth (use the search box) http://www.intelihealth.com/ih/ihtih/wsihw000/408/408.html

peacehealth consumer information (use the search box) http://www.peacehealth.org/

emedicinehealth first aid and consumer health information list of topics from a to z http://www.emedicinehealth.com/script/main/art.asp?articlekey=60185

encyclopedia of surgery http://www.surgeryencyclopedia.com/index.html

lab tests online http://www.labtestsonline.org/

for sites aimed more at healthcare personnel:

merck manual of diagnosis and therapy (use search box) http://www.merck.com/mrkshared/mmanual/sections.jsp

family practice notebook (use search box) http://www.fpnotebook.com/index.htm

medicine net diseases & conditions a to z index http://www.medicinenet.com/diseases_and_conditions/article.htm

cleveland clinic disease management project (only major diseases)http://www.clevelandclinicmeded.com/diseasemanagement/medicineindex.htm

emedicine http://www.emedicine.com/ (you may have to register to view articles, but registration is free)

web md index list of tests http://www.webmd.com/a_to_z_guide/medical_tests.htm

web md index list of medical conditions http://www.webmd.com/a_to_z_guide/health_topics.htm

web md index list of symptoms http://www.webmd.com/a_to_z_guide/health_symptoms.htm

surgical tutor.org (links are at left and top of page) http://www.surgical-tutor.org.uk/default-home.htm?core/trauma/shock.htm~right

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Specializes in Neuro.

I had to do roughly the same thing last term for preclinical and honestly, it STILL took hours, but I did find a few ways to make it take slightly less time.

I went and bought a lab test book with normal values, nursing implications, and reasons values may be high/low. I bought some of those post-it flags and flagged the pages of the common lab values I saw over and over so I didn't have to look them up in the index every time -- just flipped to the right flag.

The form I had to fill out was provided for me online in electronic form as a word document. Instead of handwriting all of the info into the little boxes, I typed everything. This allowed me to copy and paste things from previous paperwork if I had a patient with a similar diagnosis, meds, etc. I also got sick of looking up the meds in my drug book every week so I created a medication spreadsheet on excel with the drug name, class, action, side effects and nursing implications. I always made sure to check the info to make sure it was pertinent to my pt (i.e. guys don't need to worry about not breastfeeding while on a medication), but it freed up a LOT of time.

Hopefully these tips will help cut down the time a little bit. Good luck!

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Specializes in NICU.

Thanks for these valuable tips. I start nursing school in Sept. and this information will be extremely helpful. Have saved a copy of this thread to my HD. I like the idea of accumulating the meds on a spreadsheet. Should be pretty effective if I start doing that from the beginning. A shame someone doesn't publish the meds in that form so you could just cut and paste the ones you need at the moment.

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Thanks, Daytonite! You always have such helpful answers! I always look for your posts because I always learn something new. You are a treasure for all of us on AllNurses!:bowingpur :icon_hug:

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Specializes in Cardiac.

The form I had to fill out was provided for me online in electronic form as a word document. Instead of handwriting all of the info into the little boxes, I typed everything. This allowed me to copy and paste things from previous paperwork if I had a patient with a similar diagnosis, meds, etc.

This is what I did too, and it saved me tons of time.

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Specializes in Med/Surg <1; Epic Certified <1.
I like the idea of accumulating the meds on a spreadsheet. Should be pretty effective if I start doing that from the beginning. A shame someone doesn't publish the meds in that form so you could just cut and paste the ones you need at the moment.

They do....there's pre-made drug cards, PDA programs, and probably some software for this...but we were REQUIRED in first semester to make our own drug cards....that way, we were forced to actually LOOK at the information as we went through it, not just pull a card from a box....several of us prefer the PC and were allowed to create our drug cards with Word (or whatever) and that was a lot nicer timewise...

But then this semester they changed it up and we have to actually include them in our care plans!! Drat!! So I ended up doing some cutting and pasting and we're also encouraged to do these on the PC, so that helps somewhat....

Mosby's makes preprinted drug cards, but at over $35 for the box, I definitely wouldn't invest in those until you see if you can even use them....I've also read they're not complete....a good drug book -- Davis, Mosby's, etc., would probably be a much better investment...

As for the OP's question, hopefully you can do some of your work on the PC....even if you can't get it all on your PC on Monday night, can you take some time later in the week to transfer it to your PC so that you build up a database of sorts to cut and paste from?!!? I know it takes me HOURS on Monday night to do prep work, but I am usually home by 1 or 2 if I don't dawdle too much!!

Good luck!!

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Specializes in Cardiac.
A shame someone doesn't publish the meds in that form so you could just cut and paste the ones you need at the moment.

When you buy your drug guide, it usually comes with a CD. That's where I copied and pasted ALL of my med info!

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Just wanted to remark that the replies are excellent examples of why I find this site so helpful as well as interesting. Lots of good ideas. I wish I had some of these strategies avail to me when I was in school. The cut and paste ideas are great. When I went to school very few students were getting laptop computers; I don't remember anybody using their computers for much more than producing their papers (those that even had computers at all). Good luck to you.

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Specializes in Med/Surg <1; Epic Certified <1.
When you buy your drug guide, it usually comes with a CD. That's where I copied and pasted ALL of my med info!

Make sure the CD comes with the book...for some reason, mine didn't....don't remember if I purchased it from the school bookstore or Amazon, but it is a separate purchase...it's mentioned at the back of the book as an add-on.... :(

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Specializes in Med/Surg <1; Epic Certified <1.
When I went to school very few students were getting laptop computers; I don't remember anybody using their computers for much more than producing their papers (those that even had computers at all).

Well, I don't have a laptop....I'm still in the horse-and-buggy age of desktop PCs...but there are times when it's late, and a good show's on TV, that I wish I had a little laptop to drag upstairs to my couch or bed so as to get out of the bowels of my frigid basement office!!

But I would never trade in my capability to cut and paste these dreaded care plans and meds....the first time I screwed up a handwritten drug card, I wanted to pull my hair out that there was no "cut-and-paste" capability!! lolol....

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Make sure the CD comes with the book...for some reason, mine didn't....don't remember if I purchased it from the school bookstore or Amazon, but it is a separate purchase...it's mentioned at the back of the book as an add-on.... :(

I have pages and pages of drug info - when I had a new patient, I'd cut and paste the particular row of info on a particular drug into a new table. It doesn't take much to learn how to manipulate microsoft word in this way. If anybody wants my word file, please send me a private message (PM) or email me through my profile page and I send it to you.

For new meds, I'd first enter it on my "master list" then cut and paste the row in a new file. Obviously, some of the info changes, dosage, times, and purpose for prescribing.

I had one instructor, however, who insisted on everything being handwritten because she felt it was the only way to really memorize all the meds - not everybody learns this way, though.

Diahni

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