Tell me about your "brain" or "cheat sheet"

[DeLana_RN, BSN, RN]

In my first job out of nursing school I was responsible for 8 stepdown pts at a time (that's right, 8). So I made up a sheet with 8 columns (I normally used 2 of them, to account for new admits after up to 4 of my pts were discharged each day*).

For each pt I had a box for name/age/dx/dr; code status (DNR?); med times, IV meds; tx's; IV access/central lines/trachs/vasoactive drips; other important info/orders/reminders. I would keep this on top of my clipboard as a face (overview) sheet for my report sheets (where I recorded assessment findings for the pts). This worked well for me (although it did take some time to record all this info.)

Later I worked in an outpt facility where charting was minimal, so I didn't need this kind of task sheet. But I still was never found without my basic "brain", which I started using as a nursing home aide and even use today as a hospice house volunteer: a 3X5 spiral notebook that I keep in my pocket. It's amazing how much you can record there

Good luck to you!

DeLana

*No, I never left on time; there was so much to do that even very experienced nurses had hours of OT to do their charting after their 12-hour shift was over. But I digress....