Organizing my workday at clinicals

Students Student Assist

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I am having a hard time prioritizing at clinicals. My classmates seem to have everything laid out and in order. I find it difficult to start my day and to things orderly and not to confuse myself or make my day difficult. How do you plan your day on a med surg floor? The forms we use are a little confusing. What forms do I need to have on me to make my day go smoothly? I don't want to have to carry too much paperwork around. Any comments or suggestions are greatly appreciated.

IaCountryGirl

157 Posts

I don't carry a ton of papers with me, everyone carries a clipboard. We get the patients kardex printed out which includes their plan of care. When I get the kardex, I find a blank spot and write out HR, BP, O2, etc so when I get those vitals, I can fill them in quickly.

First thing I do when I go into a patients room is I introduce myself, get vitals, do an assessment, writing all pertinent information as I go. Next, I get into their eMAR and check to see when their medications are coming up and make a mental note- if it's one of those patients that have a bunch of medications at varying times, then sometime I write it on the kardex. Next I take care of any other stuff- if they have no plans to go anywhere, then I check to see if they need new linens, new gown, do they need/want a shower, do they need to ambulate. I always ask my patient what they prefer to do when.

trulyblessed2

35 Posts

Thanks. How many patients do you generally take care of a daily basis?

Some instructors won't let us carry clipboards, some will. When I cannot, I get super organized and utilize my pockets with all important paperwork. We have school specific things to fill out and med sheets with lots of info on that patient's meds.

Specializes in IMCU.

I made one simple sheet of paper with time marks on it. Like this......

15:30

- head 2 toe rooms 305 & 306

- Zosyn IV rm 305

16:00

- hourly comfort round

- complete initial charting start progress notes

17:00

- hourly comfort rounds & reposition 305

- BGM room 306 & SS insulin

- bolus H2O for 305 g-tube

18:00

- hourly comfort rounds

- chart intake

19:00

- hourly confort rounds

- vitals 306

Just carried it through until the end of shift. It was simple but it worked for me. I put in med-times and everything. When something came up I added it. Everything could be ticked off. I also had a little brain sheet with vitals, important labs and assessment data.

KristeyK

285 Posts

Specializes in Private Practice- wellness center.

I have one simple form I carry with me. The top half is info that I get from report at the beginning of the day, along with room for vitals, and an area for anything I should note from my head to toe assessment. (If something is within norms, I tend to not jot that down since my school paperwork has boxes on it to check for that.)

The bottom half is 12 squares, each with a different hour written in it. That's where I go in and write down what time each medication is due. If it's someone I need to track I&O's on, I make sure to write it down in those squares.

Other than that, I do carry one of those REALLY small spiral notebooks in a pocket just in case I need to take further notes on something. However, sitting here writing this makes me realize I have the entire back side of my paper that I carry with me to take notes on, so I may stop carrying the spiral notebook. LOL. (Sorry, I am one of those people who refuses to be a kangaroo. I keep my stethoscope around my neck, two pens and my scissors in my pocket...so the smaller the amount of paperwork I carry, the better. LOL)

Specializes in IMCU.

I agree with KristeyK -- I stopped carrying the little notebook in 1st semester.

I would ask for tips from your instructor and/or others in your class too.

SNIXRN

269 Posts

Specializes in Critical Care. CVICU. Adult and Peds PACU..

You have to find a report sheet/brain sheet that works for you - it will help prioritize your day. My report sheet has name, allergies, doctor, dob at the top. Then it's divided in two part below that - one side for assessment, the other listed with time slot boxes. I circle the time meds are due, I also write down vitals, output, etc in the specific time boxes as they occur. If it's a task I have to do for the day, I write it in the time slot and highlight it. If you want I can email you a copy.

Jessicias85

91 Posts

If you want I can email you a copy.

I'm not the OP but, I would love a copy of this!!! my email is [email protected] if you would be so kind!

trulyblessed2

35 Posts

Yes, please could you copy and paste it to this thread.

Thanks a lot

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

brain sheets.......here are a few.

doc.gif mtpmedsurg.doc doc.gif 1 patient float.doc‎

doc.gif 5 pt. shift.doc‎

doc.gif finalgraduateshiftreport.doc‎

doc.gif horshiftsheet.doc‎

doc.gif report sheet.doc‎

doc.gif day sheet 2 doc.doc

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

i made some for nursing students and some other an members (daytonite, RIP) have made these for others.....adapt them way you want. i hope they help

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I didn't realize this was an old thread......but the sheets are good for everyone.:)

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