Organizational Sheets.....What do you use?

[LoveMyBugs, BSN, CNA, RN]

I am a 2nd year student, and I had my first day of clinical for the year today:yeah:

This is the year where I get to have more than 1 patient. So I am asking all of the experienced nurses out there, how do you stay organized? How do you plan your day and keep all your patients straight? What system works for you?

I spent the day shadowing a nurse, where she had 4 patients and had half sheets of paper for all 4 of them, but she seemed very frazzeled and kept forgeting things and having to go back into the patients room.

My school stresses that we need to be organized, but that we need to figure out what works best for us......so what works for you?.....and maybe that might work for me:clown:

[Virgo_RN, BSN, RN]

I designed my own report sheet. Each patient had a quarter page. Each quarter had a space for the patient's name, DOB, diagnosis, physician, and medical history, a space for abnormal assessment findings (including any wounds, tubes, or drains), a space for pertinent lab values, a column with times where I could note scheduled meds, treatments, procedures, etc., and a space for jotting quick notes, like new developments or discharge planning.

[AusNurse2B]

We get one page for patient handover with all relevant details on it, then on the back divide it into blocks with patient down the side, then across the top is the times hourly.

700 800 900 1000 1100 1200 1300 etc Notes

pt x

pt y

pt z

then just fill in what needs doing for the hour per patient. I cross off what I have done as I go.

[DeeAngel]

If you search there are other attached organizational pages to be found here. I am assuming you are referring to a form that will get you organized in report so I will attach the one I made for myself. When getting organized I use a yellow highlighter to highlight pertinent information. I like the landscape view because you can fold the page over on itself, to where the names appear and use the backside of the paper then to make organizational notes.

Report Form.xls.zip

[cherick22]

I have a report sheet on each of my patients. They are stapled together. I set them up exactly the same. The upper right is where I put meds I will be giving and what time. Next to that I'll put foley, NGT, Neuro checks, PCA, ect...I draw a box next to each task I need to complete. When completed I put a checkmark in that box. Another thing I do is use a highlighter to draw my attention to things of importance...ie DNR status, NPO for OR ect..

You will find a system that works for you and it takes some time but it will happen. Everyone does it differently...I have even had people criticize my report sheets..I just laugh at them because when I leave at the end of my shift I never have to wonder what I forgot....

[RNperdiem, RN]

I believe the key is learning to get back on task after repeated interruptions.

For example, I am going to the supply room to get a new bag of IV fluids to replace one that is running low. On the way there, a family member will have a question, the other patient will need suctioning, and then the lab will be on hold on the phone for me. After taking care of these matter, sometimes I wonder where I left off.

Getting frazzled is often the results of losing your train of thought or having what you were doing interrupted over and over again.

I am a believer in lists.

Nursing report is list making time.

[sasha2lady]

well..I work in LTC and we use a report sheet that is blocked off with each persons name and room number....the blocks are big enough to write in any info that occurred on each shift and night shift starts a new one each night when they come on. We still use paper MARS so I am a firm believer in STICKY NOTES....but they have to be bright colors. When I need to write out a standing order or if I give a PRN or need to go chart a temp I put a sticky note on that pts mar with my notes on it that I need to go chart. I also put sticky notes on my report sheet to remind me of what I need to restock on my med cart (needles, OTC's, lancets etc) As long as I see that bright note hanging out of my Mar...I know there is something I need to do with it. It helps me out alot. Plus...in my report sheets..I highlight pertinent info. I also pull out all my charts and line them up in order for when I sit down to chart. I have my own section of the nurses desk that I sit in so I can see down my unit. When I have to call the doc about things...I have the chart, the mar and labs in front of me before I call. If its a lab Im calling about, I write what the last ones were also. Its a good little cheat sheet for me. Gets me through the shift.

[MERRYWIDOW46]

I use a review of systems and time sheet combination. I have one sheet my max patient load on IMCU is 5 so I divide paper into 5 sections, on front get report....N=Neuro, R=Resp, CV=Cardiovascular, GI/GU self explainatory, Skin, Lab, Misc. Have pt label, section for MD, DX, Allergies, and History.

On back each patient has a section timed 0800, 1000, 1200, 1400, 1600, 1800....8 & 16 I write assess, 8, 12, 16 VS, 8, 10, 12, 14, 16, 18 MEDS, 8, 12, 16 FS, if meds due at odd hour I write time and Meds under closest even time.....

I also try to check orders every 2 hours, plan tasks and have all necessary supplies and equipement together before going into room.

Frist rounds of day I ask patient how they'd like the day to go. Often with testing can't be perfect, so I learn to regroup and take advantage of times when patients are not around and able to go pee, have coffee, or eat lunch.

Good luck.

[gentle]

SBAR

Each sheet has SBAR format. This is now required for many hospitals as it conforms with regulations stressing the importance of consistent communication across disciplines.

Situation

room, diagnosis, patient name, age, isolation advance directives allergies etc.

Background

med-surgical history

Assessment

what's going on with the patient in this hospitalization. organized by systems.

Recommendations

what tests are we waiting results for.

who needs to be called - ie. consults for doctors or ancillary services or outside vendors who will be providing follow-up care for the patient.

To the far right hand side i write down the times for medications and treatments. and cross off each one as i go.

I have one form for each patient. I keep the forms in a notebook separated by dividers.

At the end of each shift, each nurse, has my SBAR-which I hand off- and use as a talking tool during report. The nurse may keep the form or pitch it which ever they choose. I also try to write labs on these as well, i fold it half over length ways and write pertinent labs on the back.

I have struggled with organization for a long, long, what seemed like an eternally long time. One day, it clicked hope this helps.

BTW, I now let everyone else be responsible for their own part of the puzzle in caring for the patient. I don't help unless I have to do so, which seems mean to some but ya know what, they need to start paying me more to do Case Managements job, and the CNAs job if that's what they want done. I'm the type of person who goes way beyond my boundaries to help others. I have been counselled regarding this issue repeatedly by superiors and by friends. Now, I let everyone handle their own issues - especially at work.

[Ruthfarmer]

If you are at a facility that has computerized charting, you may be able to print yourself a "hand-off" report which very succintly tells you all the crucial details about the patient. You can highlight the info as you receive report. Then you can print yourself a copy of the MAR and staple the report to the MAR. I find that saves so much unnecessary writing. You can also do a search of allnurses.com and you will find several really good "brain" or report sheets. You may want to pull certain elements from different forms and create your very own. Good luck to you.