Organizing my workday at clinicals

[trulyblessed2]

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]

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]

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

[BacktotheBeach, ADN, BSN, RN]

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.

[DolceVita, ADN, BSN, RN]

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]

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)

[DolceVita, ADN, BSN, RN]

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]

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]

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]

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

Thanks a lot

[Esme12, ASN, BSN, RN]

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

mtpmedsurg.doc 1 patient float.doc‎

5 pt. shift.doc‎

finalgraduateshiftreport.doc‎

horshiftsheet.doc‎

report sheet.doc‎

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]

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