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.
Here my report sheet that I use. Have extra space below where I write my labs and I use side margins to write my vital signs through out the shift.
Angela
Here is one that I use on MedSurg with 5-6 pts. I got it from someone on this website and then modified it. I put the pt stickers in the upper left area so I have access to their admit date, DOB, Attending, and their acct no. Hope it is of some help. I use legal size paper so I have enough room.
my floor prints out what we call SBAR sheets. The front of the sheet is divided into fours -- Situation, Background, Assessment, Recommendations. The patient's name, age, Dr, drug allergies, and consults are printed on the top of the page. Under Situation is provided what the pt came in for; under Background is labs, etc.; under Assessment is the last shift's assessment; under Recommendations is the meds the pt is on. Then I write the pt Hx up at the top of the page. In the back of the sheet, I write down the pt's story, what happened in the ER (what meds they gave, etc), any other important little things I need to know such as when the next APTT is due or if the pt is ACHS, tests the patient may have undergone or is to undergo, and any updates for if I come back another night and have the same pt and just need to know changes. And I'm very, very fond of sticking colorful sticky notes on my SBARs so I can keep track of tasks that I MUST perform during the night.
It works for me. Although it does look very confusing when I describe it, lol.
LuvofNursing, BSN, MSN, RN
145 Posts
Here is what i use. on the back, i write down all the times, hour by hour. I write down EVERYTHING that I need to do, regardless how miniscule it seems (recheck pain 1 hour after giving pain med, etc).
the two documents are the same, not sure if they will open.... give it a shot.
N9 - Clinical Worksheet, 5 pts.pdf
N9 - Clinical Worksheet, 5 pts.doc