Share Your "Brain" Sheet

Specialties Cardiac

Updated:   Published

Hello. I want to see how your Organization/Brain sheet is set up to get ideas before I make my own. Sharing this will be of great help.

Specializes in Cardiac/Telemetry, Hospice, Home Health.

I use SBAR (status, background, assessment, response) as a foundation for my report sheet. It is handwritten so I cannot post it but I love it.

Basically in rows going down I have a line for each system (N,C,R,GI,GU,I,MS,PS,M). "M" is for metabolic which I also use for for comfort issues.

Then in columns going across I have DX, HX, Status, TX, My ROS, Notes re D/C planning, status changes, etc.

I can then easily talk about their diagnosis down the line, I see the hx and how it may affect the big picture, status is the nurses notes to me, tx is what are we doing, my review of systems as I do my own assessments, then notes on changes that need to be made etc. I like seeing the progression as it relates to each system as I run my eye across the paper. It help me think critically.

Plus I always feel prepared to call a doc if I need to.

I have some smaller boxes to the side that are VS, Meds, Labs.

I also do a quick list of ALL the TYPES of meds (just classifications, like beta blkrs, ca ch blkr, lax, etc) the pt is getting and not just the ones I am administering on my shift. I need to see at a glance what is affecting this pt.

I use one whole page for each pt. Most all nurses here do because our pts are complicated and we have a ratio of 3-4. I designed the page though so I can fold it in quarters and the med timeline and space for "to do" is on one quadrant and I can review it quickly as I go through the night.

1 Votes
Specializes in medical, telemetry, IMC.

Here's my report sheet!

I use a binder with dividers and I use one report sheet for each pt. The report sheet goes into the pocket of the divider and then I print out the mar (we have emars), the pt's labs and the previous shifts vs every morning after report.

Works well for me! ?

report sheet 1 pt.doc

1 Votes
Specializes in PCU/Tele.

Here is my tele unit brain (SBAR). If possible, I have each patient's SBAR followed by their eMAR. Not all facilities have the eMAR, so then I have another crazy brain med tracker worksheet I made to keep me on target.

Then...

I do a little origami folding magic thing that gives me the appearance of being more organized than I am. I don't really believe it keeps me more organized, but I feel calmer when I see that at least my papers appear organized....

If there is a printable copy of the facility's quick reference guide for things JAHCO or State might question me on, (who is your safety officer, where is your blah blah...) I print that on a colored sheet of paper and us it as a cover/top sheet...the different color makes my brain easier to spot from accross the room, the cover sheet has answers I may need some day, and it adds a layer of HIPPA protection.

As a traveler, I feel like I have this one thing that is a constant. Ahhhhhh.

SBAR.doc

2 Votes

To: SunInMyHeart - I would love to see a sample of the worksheet you describe. It sounds exactly like what I need to be able to see the "whole picture", which I have trouble doing. Is there anyway you can upload a sample? Thanks!

1 Votes

Thank you everyone, these will make my life easier and help put my mind at ease

1 Votes
Specializes in Psych, ER, Resp/Med, LTC, Education.

What kind of floor /unit will you be working on and how many patients do you get a shift? Min? Max? Do you have residents or NPs or PAs that work as teams at your hospital? If you can answer these questions for me and maybe a few others I can put a couple different styes togehter for you....... I have done this a couple of times for nurses on units I would float to when they would see my worksheet and want to use it--but I tweaked it to fit their unit more specifially.

So let me know if you want some help.....send me a private message if you like that way I can ask any other info I may need........

1 Votes
Specializes in ICU/CVU.

I work in the ICU and occasionally float to Tele & the CVU. I made my sheets and they have become popular among some of the staff I work with as well. Honestly, I would be lost without them. The items with check boxes like "PP, KD, IVMD and PAIN" are just charting reminders for myself. Those are the things we must chart on every patient. It has an area for most things I would need a quick reference to if asked by a doc. I made it with Excel, but posted as an image here. Enjoy.

1989726698_Picture1.png.5a6f14bb8955ce06b5ba5e0d7ea8cd63.png

1 Votes

Hi, I'm new and just finished orientation but I've gathered lots of tips from nurses along the way. Haven't started using my brain sheet but I think it incorporates what the other nurses are doing. It prints out on legal paper with a front and back. Front is in SBAR style; back is sectioned to write notes w/a water mark of Mother Teresa to remind me it's all about the patient. I will try to attach them. Hope they help. :heartbeat

PS I'm on a Coronary Care Unit! Yippeee!

PPSS: Darn. I don't know how to attach file in this messaging system. If you PM me with your email I'll send you the attachments in word. Good luck.

1 Votes

Here's my nurse brain. I know...it's small, but I don't like clutter. All the little letters in the lower right hand corner stand for things I need to remember to complete, like F = flowsheet, M=meds, X= I/O's, etc. . When I've comleted those things for the day, I mark it off. That way I'm not wasting my time later checking to be sure I completed something. Lower left hand corner is left blank for whatever pertinent labs/procedures.

SORRY...just realized I don't know how to attach files to the post. And now I can only edit...not delete my post.

1 Votes
Specializes in Tele.

Here is my :twocents:. Like some of the other posters, I use 1 sheet per pt and place them in a divided notebook along with my emar. I have tried to cut down on the amount of writing and set it up to circle what I need. Let me know if you have any questions. This is verson 6!

Report sheet 5wh v6.pdf

1 Votes

I think it's one of those things you really have to figure out what works best for you. I work in a nursing home currently and the easiest thing for me has been to take a blank sheet of lineless paper, write the name of each patient underlined and underneath jot any alerts and use the MAR to write a schedule of the meds they will take and treatments they need on my shift. Since not much changes from day to day in the nursing home I make copies of these to use later and update them periodically. I've done this for years and not much gets past me. I keep a highlighter and highlight out each thing as I do it.

I'm leaving the nursing home for a ltac hospital, though, and hear I'm in for a rude awakening. My little system may not work so well there.

1 Votes

Thanks for sharing and good luck with your new position. I'm loving the tips that I've been getting about brain sheets. My recording of the data is getting sooooo streamlined thanks to everyone's input. Later,

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