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Discussion

Staying Organized??? HELP PLEASE!

Does anyone have a good layout for your brains? When I was in nursing school it was given to us for the first 3 semesters, then we had the opportunity to make our own and play with other's as well. I always felt organized but something happened between then and now!

I first started as a GN in June and wrote report on one piece of paper that was separated for each pt. I then had a matching piece of paper with only rm#, pt name and important information that I used during the day along with the med sheet (we computer chart). After I failed the NCLEX the first time I worked as a CNA from Aug. until Dec. and again used the same format but only had to record vitals and ADL's on it.

Now that I am practicing as a nurse I feel like I am so unorganized and seem to end up with a million different papers and only have 2-3 pt's. What happened to me? I have no format for recording and keeping track of my pt information during the day and feel as if I completely forgot how.

We get report on all pt's at the beginning of shift (work in family care so have PEDS, PP, L/D, and some surg) then at the end of report we delegate the pt's to each RN. I am wanting to find a simple layout that will allow me to keep my information on just a few sheets (know I will have more pt's when off on my own) and maybe 2 pt's per sheet with organized layout for: Report, pt information, meds, interventions, ADL's, and VS etc... I know if I can get myself organized again I will be much better at giving report too. Nobody in my unit really seems to use anything but a blank piece of paper when report begins, but they all seem to have their own little things they use to keep it all together.

Has anyone come up with a good idea or am I the only one who has already forgot what I learned from nursing school on how to be (and remain throughout the day) organized?

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    Either nobody has any ideas for me because we are all feeling the same way or I am SO unique in my quest that everyone has been left speechless...

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    rags said:
    Either nobody has any ideas for me because we are all feeling the same way or I am SO unique in my quest that everyone has been left speechless...

    I'm looking for this too! Let me know if you ever find a good one!

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    • Author

    I will be sure to share if I find a solution.

    Promise!

    rags

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    I did a search under Organizational reports and something came up.

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    I take one piece of paper 8 1/2 by 11 and divide into 5 horizontal columms

    ___________________________________________

    pt name rm #

    import info (tests,abn labs, etc) tele rthm

    all new orders

    IV info(tpn heparin, etc) ___

    pt name rm# tele rhythm

    important info (tests,abn.labs,

    all new orders

    IV info(tpn, heparin, etc)_____________

    You get the idea, too much info on paper will confuse you. Hope it helps a little:trout:

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    I'm only in my second semester, but I worked with a RN last semester who had 1 - 8.5 X 11 sheet that she had folded in half and then divided up by pt with teeny tiny notes on it...she told me that that was her "brains" and she had been a nurse for 18 years!!

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    • Author
    Icess64 said:
    I did a search under Organizational reports and something came up.

    What'd you find? Do you have a link?

    rags

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    I have ADD and was constantly putting notes and papers down and not knowing where they went. Besides being frustrated, I was worried about info floating around and HIPPA.

    What I did at clinicals to stay organized was to go out and buy a thin 3 ring binder and a green highlighter. I would print off pt. data sheets at the beginning of the shift, 3 hole punch them, and put them in the thin binder and label the front of the binder "confidential".When I went to take report I would highlight in green the key report items already on the data sheets, and add my own notes as needed. IF you don't have data sheets, then you can just use blank paper, I kept a seperate paper on each patient and I carried that binder around with me everywhere I went and I never had to worry about losing a piece of scratch paper with vitals on it ever again. It might not seem practical to some, but it got me organized quick and my clinical instructor was impressed with how quickly I turned things around. I was also very diligent about making sure I had the binder when I left a pt. room, and the system worked good for me. After you do it for awhile you'll start to realize that you can leave the binder at the nurses station and come back to it when you need it. That's my two cents for the day!

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    This is what I use. Holds 12 pts when printed on front & back. I also print in landscape....hope this helps.

    Shift Sheet.doc

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    I used to use a book called RNotes: Nurses clinical Pocket guide by Ehren Myers you can buy it at amazon.com

    It has erasable forms

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    rags said:
    What'd you find? Do you have a link?

    rags

    I have actually found a few. If you PM me your email I can send them as attachments (there are like 5) so that might be easier than attaching them here...

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    If you could, would you be able to send them my way too??? I have been searching high and low for the same thing.

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