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Organizational Tool

Posted

hi,

in the course of my job as a clinical instructor, i have encountered students having issues with organizing their patient information (which is i could understand cause they are still students and need guidance). in our case, students have to go to the hospital the day before to pick up patient information. some of them will write in a small notebook and some will write in loose papers (that easily get lost). there are some others, for some reason or another, will miss important information that they need to fill up their concept maps (e.g., vital signs or lab works). so, i came up with the organizational tool (i have copied and pasted below, can't attach the file probably because it is more than the required) below. i gave the students copy, they can fill it up with the patient information and hopefully, they will not forget some of the most important information they need.

on their last day, i asked them to turn in a revised version to tailor to their individual needs.

if anybody is interested, please feel free to copy and paste, edit or revise according to your need.

thanks.

oranizational tool

patient's initials: _____________________ age: __________________ rm. no: ______________

marital status: ______________________ sex: __________________

date of birth: _______________________

allergy: medications: _______________________________ food: _________________________________

contrast media: ___________________________________ environmental: __________________________

primary md: __________________________________________________________________________________

consults: _____________________________________________________________________________________

date of admission: _____________________________________________________________________________

chief complaint: _______________________________________________________________________________

diagnosis: ____________________________________________________________________________________

health history: ________________________________________________________________________________

_____________________________________________________________________________________________

date/surgical procedure: ________________________________________________________________________

date/procedure: _______________________________________________________________________________

results: ______________________________________________________________________________________

admission vital signs: bp: ________________ hr: ______________ rr: ___________ temp: ___________

o2 sats: ____________

date of visit vital signs: bp: ______________ hr: _____________ rr: _____________ temp: ___________

o2 sats: __________

o2: _______________________________________ respiratory tx: ______________________________

ventilator: tv: __________ fio2: ______________ rate: ____________ ac: ___________

imv: ________ ps: ________________ peep: ____________

iv: ________________________________________ diet: _______________________________________

iv site: _____________________________________ feeding tube: ________________________________

date of insertion: ____________________________ formula: ____________________________________

foley: yes no date of insertion: __________ date/ekg: ___________________________________

date/chest x-ray: ____________________________

abg: ph: __________ pco2: __________ po2: __________ hco3: ____________ o2 sat: ____________

wound (if any): _____________________________________________________________________________________________________________

lab:

date: _________

on admission:

date: _________

day pick-up info:

lab:

date: ________

on admission:

date: ________

day pick-up info:

wbc (5-10)

glucose (70-110)

rbc (4-5)

bun (5-26)

hgb (12-16 female

(14-18 male)

creatinine (.5-1.5)

hct (37-47 female)

(42-52 male)

calcium (8.5-10)

plt ct. (150-400)

potassium (3.5-5.0)

magnesium (1.5-2.0)

ua

sodium (135-145)

fingersticks:

date: _________

on admission:

date: _________

day pick-up info:

fingersticks:

bedtime

date: _________

on admission:

date: _________

day pick-up info:

blood glucose

(chf) lab:

date: _________

on admission:

date: _________

day pick-up info:

(cp/cad)lab:

date: _________

on admission:

date: _________

day pick-up info:

bnp

100-300 pg/dl = hf present

300+ = mild chf

600+ = moderate hf

900+ = severe hf

troponin 1 (

(onset: 4-6 hrs, peak: 12-24 hrs, return to normal: 4-7 days)

echocardiogram

myoglobin

male: 10 - 95 ng/ml

female: 10 - 65 ng/ml

(onset: 1-3 hrs, peak: 6-10 hrs, return to normal: 12-24 hrs)

ef (60-70%)

ck (8-150 iu/l)

ck mb (0-3.9%)

lab:

pts. on coumadin

date: _________

on admission:

date: _________

day pick-up info:

lab:

pts. on heparin

date: _________

on admission:

date: _________

day pick-up info:

pt (10 - 14 seconds)

ptt (32 - 45 seconds)

current medications:

drug

dose

route

frequency

remarks

It's me again,

It did not come out right, but if anybody is interested, just let me know and I can email it. Thanks.

could you email it to me?

I thought it was great! Thanks!

Edited by BBFRN
email addy in post

donnasRN

Has 3 years experience.

Wow, that's great. If you can email it to me via my profile, it will be greatly appreciated.

I am starting nursing school in the fall and I have so much anxiety already!

Edited by BBFRN
email addy in post

Hi All,

I have sent the organizational tool to your emails. Please let me know if you received them.

Thanks.

elprup, BSN, RN

Has 2 years experience.

I just graduated recently. Our sheets were HUGE, one side was all info, like you listed in your email. The back was where we had to come up with Problem (CHF, DM, etc) and map it all the way down to the cellular level, and incorporate meds, labs, treatments, symptoms and actually draw lines to where they correlated in our map. It was totally crazy....but really helped us put it together. Hope you got some ideas.

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

there is an assessment form that includes historical questions in the center of taber's cyclopedic medical dictionary under the listing of nursing. in regard to the information that should be obtained from a patient's chart, this is listed on post #23 of this sticky thread in the nursing student assistance forum https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html - health assessment resources, techniques, and forms. another reference that has a form for collecting historical information about a patient is contained in pamela mchugh schuster's book concept mapping: a critical-thinking approach to care planning.

vintagestudent

Specializes in Just started in HH.

Wow, this is very helpful. Thank you! :flowersfo

BBFRN, BSN, PhD

Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research. Has 15 years experience.

A gentle reminder to our members;

Please do not post your email addresses in the public message boards. It is against our TOS, and they will be removed. Other members can email you privately via your profile.

Thanks! :)

Edited by BBFRN

NewRN2008, ASN, RN

Specializes in Ortho; Gyn; Urology; HBOT; Emergent. Has 8 years experience.

Okay, first of all, your students must LOVE YOU, and if they dont, kick em in the head. lol. our instructors had us make our own to make sure that we were organized, we didnt get things handed to us on a silver platter! u rock! totally not being a jerk in any way, please dont take it that way.

Anyhow!! if you think you want some other ideas, use that search bar on the top of the page and type in some key words r/t that type of sheet you are looking for, and you can see many many other types that other ppl have kindly posted. i think its a great sheet for students though!

great job!

-H-RN

donnasRN

Has 3 years experience.

A gentle reminder to our members;

Please do not post your email addresses in the public message boards. It is against our TOS, and they will be removed. Other members can email you privately via your profile.

Thanks! :)

Thank you, sorry about that! :imbar

I'd like to see it please.

Hi 2BSure,

Send me a private message with your email address. I will be glad to send it to you. Thanks.

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