what to put on your worksheet?

Daytonite, BSN, RN · Nov 2, 2005

Hey, Megan!

Sorry, I just noticed your post this evening. Let me give you a little help on this. Do you have a report form that the hosptal is supplying for you? Does it include the patient's diagnosis, surgery, surgery date and doctor's name? Those things are important to know because it kind of narrows down the important things you'll want to focus on for each of those patients. The only time I worried about diets is if they are something special like NPO, clear liquids, full liquids or pureed. I usually like to know what labs were to have been drawn that morning for my patients' for two reasons. One, to check to make sure they were done. Two, to check them quickly to see if anything is out of whack that the doctor needs to be notified about. Years have taught me not to depend on a lab technician to call abnormal results to me. Same thing with x-rays. I want to check to see that they are getting done. I don't worry too much about x-ray results because x-ray is pretty good about calling doctors when they see something bad. I used to go through the med sheets of my patients and just check to see what times they were due. On the back of my report sheet I put a little grid with the times I had medications due. I didn't usually write down what medications they were except for IV piggybacks. Sometimes I had to plan out the piggybacks because some patients had two or three different antibiotics that had to be given and some of them were scheduled for the same time. So, I wanted to make sure I got everything all sandwiched in. I also noted by each patient, who had an IV and what fluid was supposed to be running.

For your ortho patients I think I would want to make some kind of indication as to whether the patient had a cast, traction, or external fixation. I'd also list any dressings that needed to be checked and/or changed. I used to make room for the vital signs that would be taken during the shift and blood sugars. As these were done I would also write them on my report sheet. That way I had them and didn't have to go running around to get the nurses notes to find that information. If someone had a foley cather I used to make room for I&O on my sheet, mostly as a reminder to myself to make sure the foley got emptied at the end of my shift and also to check the patient's output just in case I got busy and forgot and the guy turned out to have a ridiculously low urine output that needs to be reported to the doctor.

Right now, off the top of my head, those are the things I would want on my report sheet. Make sure that on your immediate post-op patients that you are checking them for first voiding, what any dressings look like, IV fluids running, and need for pain medication. I never liked the report sheets at any of the places I worked, so when I started using computers years ago I began developing my own report sheets. They were much more functional for me. I used to put the day and date at the top of them. You may laugh, but for all the things I have to do during the shift, it's easier to have the date to look at rather than have to think about what day it is. I also included frequently called telephone extensions (pharmacy, lab, x-ray, transport team, IV team). I used a lot of color also. NPO was always written in red ink on my sheet. Anything that I had to make sure I got done during the shift got circled a couple of times in red ink so it stood out and when I finished it I would just put a slash through it. I used the back of the sheet to write notes, notes on report I took from the ER or OR on a patient I was going to get, and doctor's orders as I took them over the phone. These sheets went home with me in my pocket unless I was required to leave them at work in something other than the trash. I often brought my report sheet from the day before and kept it folded in my opposite pocket so I could refer to it if needed. At home, I kept them in a folder on my desk for at least a couple of months. You never know when a telephone number or a name you jotted down on them in going to be needed again.

These report sheets become very personalized tools for each nurse. You too will develop your syle in one over time. Is there anything else I can help you with? Feel free to PM me.

P_RN, ADN, RN · Nov 4, 2005

Daytonite that is agreat post!!

One other thing I did was get a pocket sized address book at KMart/Walmart etc. Using the alphabetized pages I would put Dr. S's phone number/pager number etc. on the "S" page.

On that same "S" page I would put the telephone # for SUPPLY or SURGERY or SMAC computer code. Equipment starting with "S" would go there too. It saved a great deal of time not having to stop and look up stuff back at the desk.

nmoore67 · Mar 31, 2008

Daytonite,

Love your suggestions!!! I am still looking for the perfect report sheet (even though my manager wants us to use a specific one that I hate). Thanks. :yeah:

suehp · Mar 31, 2008

good suggestions...I usually use a highlighter pen for anything that needs doing on my shift...a good visual for me :-)

november17, ASN, RN · Apr 5, 2008

I keep the "most likely to be called" phone numbers on a sticker on the back of my ID badge.

Pharmacy, Central Supply, Blood Bank, Main Lab. I know most of them by heart now, but sometimes I forget so it's nice to have them handy.

My report sheet is also a personalized version of the standard one that they hand out.

Unfortunately it's saved onto a CD in my locker, and I don't have any copies to go off, but it is basically an SBAR form. 2 patients per page split down the middle (so I carry three or four sheets on a clipboard). Each section gets a box..

top box: Sticker with pt's name, age, MR # (comes in handy to have on-hand).

Situation: Why they're here/procedure done/whatever, post op day, current xrays, labs, VS (I have my own system for writing this stuff down to save space...I don't think anyone would be able to read it except me !!).

Second box:

Background: Any history that is pertinent to the care (like, has one leg or diabetic). I don't write it all down because we use EMR and it is easy to access the rest of it if necessary.

Third box: Assessment stuff. What degree the CPM is at, last BM, edema, dressings, vacs, chems, etc.

Fourth box: A pre-filled out list of nursing interventions to remind myself to do them (like, ice, elevate, etc). New orders, the "to-do list" for my shift, stuff the next shift needs to do, labs/tests to look for, the discharge plans.

It's kind of a fill in the blanks kind of thing. Often I simply copy info from yesterday's sheets onto the new ones. If I have all the same exact patients, I use the same sheets from the day before, I'll just scratch out stuff that's changed and update it accordingly.

I also keep another seperate sheet with a grid; the hours of my shift at the top, and then spaces to write the room numbers in on the left side. I use that to keep track of when meds are due for the individual patients. At the bottom of that sheet is my "S-List" which is where I put the room/bed numbers of patients that haven't had BMs in 2-3+ days. I'll leave it to your imagination as to what the "S" stands for.

I'll try to remember to bring the CD home next time I work and post a copy that can be downloaded so you guys can check it out. I've had several of my coworkers ditch their sheets to use mine. Maybe someone will find it beneficial or even a way to improve on my sheet (that would be awesome!)

P_RN, ADN, RN · Apr 5, 2008

Our name badges initially were 1' x 3' so I made a sticky for everyone wiht the normal labs for cbc, sma7, thyroids, dig, etc.. I had a little address book with all the docs numbers, supply phone and frequently used supplies not in the pyxis, docs preferences if they were odd. like Dr Tr. refused benzoin use on before his steri strips.

I also put the residents beepers and who was on call on a white board at the station. and next to that there was a cabinet where I put all the numbers, all the beepers, how to run a code, how to fill a death cert. all the paper that would fit. along the edges of the shelves I tap[ed hard to spell words like

Endoscopicgastroduodenectomy, and Methylmethacrylate bone cement.

Friends still tell me they are all there.

OUr charts were colorcoded with orange for staff, pink for.....Clinic, Yellow for Dr. T.......

On the back corkboard I made a page for each with the color and telephone and their preferences

Right when Hipaa came they made us remove the names from the chart but you could still find them by color code.

And speaking of Hipaa you cannot take the information home.....it is only yours to use while that patient is assigned to you. SO keep it in your locker or cubby etc.

NICU_nurse2b · Jun 25, 2008

I am a new nurse and work on a ortho floor. I have tried to upload my brains. I don't think it worked. I will try again.

NICU_nurse2b · Jun 25, 2008

tried to copy and paste. sheet was not readable.

NJNursing, ASN, RN · Jun 26, 2008

We use the SBAR form, but I've tweaked it for my personal tastes.

On the top boxes I have:

Pt's name, age, room #.......allergies..........MD's Consults

History...wounds, drains, cpm, SCDs...diet, activity, NPO?

IV site, fluids............baseline vitals.............misc. box

Labs...............Output type and amt..........Accu Checks

Previous assmt................my assmt...........precautions, or 'to do' boxes for admissions.

It all fits nice and neat on one page.

NJLaurenRN · Aug 19, 2008

when i go thru my care plan i make check off boxes for things to do ex- cpm start, occult stool, urine samples. i have a 2 boxes one for labs and info like xrays of tests, the other for a time line ex- oob with PT, dr X here to assess pt, when pt off unit of test/xray. stuff like that. always know their H&H's and INR's or PTT's. and WBC. try to see what it was the day before and see progress or worsening. i have been looking around at other nurse's on the unit's way and using a combo of a few techniques. ask nurse's most of the time tehy will be flattered u asked and say their way is the best way. lol some nurses use a legal pad for stuff they can use as a quick reference of all their pt's on one page. we have a dry erase board in the pt room where u write ur name date and NA's names. i like to write.things like this (here's one of my pt's today) IVF, 2gm NA diet, CPM, SCD's, breathing exercises, ice bag to knee, F/C or make signs in each room to keep ur aides in sinc with u like strict I&O's. lately or census has been flucuating up and down so we all have been floating to different units. so i have been able to see what other units do for shift report. on my ortho unit we give report to our charge report verbally that she keeps in a binder. she gives report to the oncoming charge nurse. that way everyone is in check and knows whats going on, so if ur tied up and can't answer the phone she can let the MD know whats needed. its kinda funny but our ortho dr's have suck a great bond and respect for all of us that some of them we call for orders, tell them what we want ordered and then they give to ok for it. ok off the subject but sorry. i also write all abnormal findings during assessment or changes in status on my care plans. we don't use pre printed report sheets, but the charge does when we give her report. takes time out of ur day but in the end its well worth it. does anyone have to do daily "rounds" where u go into the conference room with a DR and case managers and social workeres and talk about pt's d/c status. had to do that the other day on a PCU floor. felt weird b/c my unit doesn't do that

suehp · Aug 19, 2008

when i go thru my care plan i make check off boxes for things to do ex- cpm start, occult stool, urine samples. i have a 2 boxes one for labs and info like xrays of tests, the other for a time line ex- oob with PT, dr X here to assess pt, when pt off unit of test/xray. stuff like that. always know their H&H's and INR's or PTT's. and WBC. try to see what it was the day before and see progress or worsening. i have been looking around at other nurse's on the unit's way and using a combo of a few techniques. ask nurse's most of the time tehy will be flattered u asked and say their way is the best way. lol some nurses use a legal pad for stuff they can use as a quick reference of all their pt's on one page. we have a dry erase board in the pt room where u write ur name date and NA's names. i like to write.things like this (here's one of my pt's today) IVF, 2gm NA diet, CPM, SCD's, breathing exercises, ice bag to knee, F/C or make signs in each room to keep ur aides in sinc with u like strict I&O's. lately or census has been flucuating up and down so we all have been floating to different units. so i have been able to see what other units do for shift report. on my ortho unit we give report to our charge report verbally that she keeps in a binder. she gives report to the oncoming charge nurse. that way everyone is in check and knows whats going on, so if ur tied up and can't answer the phone she can let the MD know whats needed. its kinda funny but our ortho dr's have suck a great bond and respect for all of us that some of them we call for orders, tell them what we want ordered and then they give to ok for it. ok off the subject but sorry. i also write all abnormal findings during assessment or changes in status on my care plans. we don't use pre printed report sheets, but the charge does when we give her report. takes time out of ur day but in the end its well worth it. does anyone have to do daily "rounds" where u go into the conference room with a DR and case managers and social workeres and talk about pt's d/c status. had to do that the other day on a PCU floor. felt weird b/c my unit doesn't do that

We just give report to out Nurse Manager and Case Manager in the morning of what things are going on with out patients...our Nurse Manager is good - if we are a bit snowed with our workload she will call Doctors and help out with Patients when she is able to....

On my worksheet I usually have their admit diagnosis, allergies, age etc and accuchecks...I put down who their medical dr/s are , whther they are DNR, what their P/T status is and I&O's whether they have an IV, what diet they are on, LBM, foley. Also make sure i know their labs too....Dr always ask for that....(if they havent looked it up themselves)usually leave a bit of room for a brief medical history too - found this useful if we have ever had a rapid response and the RRTeam have asked what their medical history is...I have seen someone give the worng history to them as they got their Pt's mixed up...