Shift Patient Care Sheets

[emmie08]

As a new grad. my biggest problem is keeping organized and task managed. I think it would be great if anyone has a 12 hour shift pt. care sheet they use to keep organized/stay on track with their patients. I would really appreciate any and all help! Right now I'm just aimlesly scribling all that I can on the back of a blank sheet of paper. I know there are some great tools out there, I'm just not crafty enough to put one together myself...and I don't know where I would start! Thanks so much to everyone, I will really appreicaite your help.

[bubbly]

The problem with patient care sheets, or "cheat-sheets" as I call them, is that you need to customize them to your own preference and patient work load. I make mine in microsoft word using the tables format. I like to type them up because they help organize my messy handwriting better. I have rows for the patients' name, diagnoses, history, labs, ivs, oxygen requirements, feedings, family issues, what to bring up to the Drs during roounds, and any supplies I need for that patient. I also have a slot for every hour of my shift where I will write down during report when my feedings, vital signs, meds, labs, etc., are due. I am also very visual and like to highlight the different categories (like meds and labs) in different colors. I cross things off as I do them and frequently add things or change the times of when I will do certain tasks. I always write mine in pencil so I can make changes better instead of having a bunch of crossed out scribbles if I have any changes. It took me quite a few weeks to finally modify my cheat sheet to what works best for me. Just keep in mind what you find especially important to the patients' care (LOL you can't put the pt's whole chart info on one sheet) and information you find yourself looking up all the time. I hope my advice helps and good luck on working on your time management and organization skills. :)

[David's Harp]

Ditto what Bubbly said, though I did post something in the "Brain Sheet" thread a little down the page. The one side has my to-do tables and the other has a blank hourly flowsheet. But it's true, you'll probably just need to do a custom one based on the needs of your particular floor and your own style. Heck, mine's a work-in-progress, as I'm only a week off orientation myself...

[elizabells, BSN, RN]

I agree with the posters above - I make my own. My floor actually stocks a few different kinds, but they never quite worked, so I took what I liked about them and tweaked it. It really depends on your needs. My cheat sheets, as a NICU nurse, are going to be very different than the cheat sheets for med-surg, LTC, L&D, even an adult ICU, etc.

What I have on mine is a huge table - 24 columns - 2 per hour. The rows are all the vitals and numbers I have to record, which is appx 20 rows to be comprehensive for all the permutations of the types of patients we have. I have about five blank rows under this. Under the table I have spaces for name, MRN, weight, gestational age, day of life, history/diagnosis, oxygen therapy, lines/IVF, feedings, meds, and recent labs, which I fill in during report. When I check my orders I pencil in the additional tasks in the blank rows under the time column that they're due. Labs, treatments, meds, etc. It's a lot of stuff on one page, but it works really well for me.

I tried to upload the file but AN doesn't seem to support Word 2007 .docx files.

A way to get started would be to hang on to your hand-written ones for a few weeks. Take off all the patient identifying info, of course. Then one day sit down and look for patterns. Figure out what info you need to get in report, and what you need to record during your shift.

[Daytonite, BSN, RN]

This is the last report sheet that I used

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