"Brain" for 30 LTC residents

[lovelypinai18]

hi everyone,

i'm starting my third week working in a skilled nursing facility on day shift as a new rn where i can have up to 30 residents. does anyone have a good "nursing brain" that they could share that would be good for writing down my residents & organizing my day? i am getting the hang of organizing my day & everything done but would like to have a nicely organized sheet where i can write everything down. anything would be greatly appreciated :)

(i've been working in ltc for the previous 3 years as a cna, so this environment isn't too new to me...)

[AZMOMO2]

Do you have a report sheet that you use with all of the names and room numbers on it? Its going to be very time consuming to rewrite all of those names every shift.

So what I did was this:

Take a clean report sheet and attach it to my report sheet that has all the off shift report on it. Highlight anything on there that is new and requires follow-up actions. IE they are waiting for a urine, or need to call the doctor etc.

Then I would put circles next to all of the names OO Mr. Jones = Mr. Jones has 2 med passes. OOO Mrs. Doe = has 3 med passes, you could put the time over it, for example 0800, 1200/1400, 1500s . As I passed meds to that resident I would put an X through that circle.

Residents that have insulin coverage and accuchecks I would highlight w/ yellow and put B___ L___

Use green highlighter for those that need follow-up from your report sheet.

If they need vital signs or other things done I would put this down on the line, and cross off once done. VS____ Charting___ Treatments______Notes:

So a line could look like this at the end of shift: XX Mr Jones B_75 L__180__ VS T97.3,P68,R24,BP 110/68, O2 2L 98% Treatments X Charting Done Notes:Mr. Jones OK, no new issues. Urine collected, req done, in fridge awaiting p.u.

Once you get used to your shift and residents, and you will, you will find a brain that works best for you! This is just what I did and there were quite a few nurses that followed the circles because it was easier to see who had gotten meds when you were chasing them around the facility during meals. it also served as incentive for me... wow look at how much I have done!

[DPRN]

My staff use a "brain" to get through their shift as well. We have all residents listed on an 8 1/2 x 11" paper in alphabetical order because our med cart is also in alphabetical order. Beside each name is a column listing their med times (which can be highlighted or crossed out if needed) and a blank column for notes. Some of my staff color code their cheat sheet by med pass (for example yellow is the AM med pass, orange is the noon, etc.). Each staff member writes notes as they desire to get through their shift. Good luck to you.

[laderalis]

When i first stated i made up a sheet on my computer at home with one small column on the left with name and room # and then a big column on the right where i would write the med pass times and blood sugars/ vitals and anything special to that patient ie: any sleeping pills, suppositories, dressing changes, extra charting. in this big column i would also write any other 'to-do's" I had this all typed up and would change it as needed. i would then bring the pre-printed form in and fill it in as i went through my day.

Now that I have been working a few months i have abandoned this sheet as i have memorised the med pass times. i just use a mini legal pad and write a spot for blood sugars, dressing change/treatments, odd pill times and to-do's without having all the "normal" things listed. Our MAR/TAR has plastic tabs that can be pulled out so I use those for normal things and push the tab in when done.