Patient Organizational Sheets

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hi everyone,

i just graduated and i'm attempting to gather my orificenal of info: report/cheat sheets, reminders, quick references, etc. (things i will need to help me stay organized :o) i would greatly appreciate it if any of you could share your forms and or advice.

thanks from a newbie rn!!:heartbeat

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search brains...

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My department prints off a run sheet that has all of my patients for the day listed on it. I sort of make my own columns on that sheet, as follows:

  1. Drsg Change/Procedures = Any dressing changes, IV changes, Catheterizations, etc. that I need to get done during that shift.
  2. Labs = List of labs being drawn so that I remember to look them up for the docs
  3. PT/OT/Off Unit Procedures = Any scheduled time that the patient will be out of the room or off the unit.
  4. Accuchecks = Reminders of which patients need their blood sugar checked and a quick place to write them in.
  5. PRN Meds = Particularly pain meds. I write it down here when I give a PRN. I like to have it right there on my run sheet so that I can see at a quick glance whether or not the patient can have another dose.
  6. Med Admin Times = A quick list of what times each patient has meds scheduled. This helps me organize who to get meds to first.

I also write down somewhere in there how a patient transfers (i.e. w/ minimum assist x1/transfer device/etc.), since I work on a rehab floor, and no one stays in bed all day.

Every unit is going to have different priorities. Hopefully others will give you some ideas, but I hope this helps. I try to condense as much information on one sheet so that I have a cheat sheet at a glance, and then I keep individual sheets on each patient where I go into more detail.

ETA: I also have my Tabers, Mosby Lab Reference Guide, and Davis Drug Guide on my PDA. Not only do I refer to them constantly, but my coworkers often ask me to look stuff up for them too. To me, they were worth the investment (SkyScape.com), but after seeing mine, another of my coworkers found some great free apps, to. Good luck!

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Specializes in Med Surg, Ortho.

Here is a link to a thread with several attachments of report sheets. My post is number 15 on this thread which has the report sheet I use for up to 6 patients.

https://allnurses.com/first-year-after/report-sheet-148952-page2.html#post3875120

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a good old fashinoed blank piece of copy paper

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Specializes in Ortho, Neuro, Detox, Tele.

On my unit we use a SBlAR report sheet, where each catagory has different info that pertains to each heading...I work ortho/neuro, so here is a rundown....

Subject....name, doctors, condition, day post op or of stay, living situation at home.

Background...code status, allergies, medical hx, tests done or to be done with results.

Assessment...by system each catagory.

Recommendation...are they going to SNIF, home, home health...do they need a consult, are they having surgery? google SBAR....

Really, you just need to develop whatever is appropriate for you...ask your fellow coworkers for their sheets or tips...good luck!

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