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Tell Me About Your "System"

First Year   (1,098 Views 4 Comments)

NursingAgainstdaOdds has 2 years experience and specializes in Med-Surg/Tele, ER.

5,626 Profile Views; 450 Posts

Here I am again! :)

I'd like to hear how experienced nurses organize their patient load and all its associated data and paperwork. I doubt I'll be able to really develop my own system until I'm really on the floor next week, but a couple things I'm considering -

  • Small 3/4in-1in binder with pt cardexes, MARs, pain scales, etc for my assigned pts (saw many RNs on this unit organize this way during clincial)
  • 4x6 in laminated cards with space for bare bones & essential pt info, to be carried in pocket and reused

I also have a PDA, which I used extensively in clinical and at work, but mostly I find this useful for looking up pertinent data rather than organizing it. I am, however, open to thoughts on this.

Additionally, I will be keeping a work journal. At this point it's really for my own records to keep track of my orientation and the pt load I carried during that orientation, what I learned, etc. If anybody has suggestions regarding a work journal (specifically how to do this type of documentation w/o a HIPAA violation) that'd be GREAT!

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Daytonite has 40 years experience as a BSN, RN and specializes in med/surg, telemetry, IV therapy, mgmt.

2 Followers; 4 Articles; 14,602 Posts; 101,572 Profile Views

I always carried a clipboard. A have a special clear plastic acrylic clipboard that I used. On it are a couple of things that I use for reference. One is a guideline for doing a head-to-toe assessment. Depending on what kind of unit I worked on I've had other things on it. I rigged a pocket to the plastic as well to hold smaller cards and such that I don't want to lose (a weight/liquids conversion table, decubitus measuring tool). I usually put copies of things like fire protocols and hyperglycemic protocols on it. When I worked on a telemetry unit I took a printed copy of our standing orders and had them laminated and carried them on my clipboard. Very early in my career I had trouble forgetting all the things I was supposed to assess and document when a patient had chest pain, so I created my own instruction sheet (had to type it on a manual typewriter--no computers then) and laminated it between two sheets of clear Contact paper. I still have it. Most important was my report sheet. Many facilities will supply you with one. Most of the time I found them to be pretty inadequate, so I ended up creating my own. Computers have helped a great deal in this. Here is the last one I used. You're welcome to use it:

[attach]5032[/attach] My Report Sheet ("Brains")

That report sheet is really how many nurses organize their shifts. I took shift report on it and gave shift report from it. I wrote notes on it about patient assessments and patient information as I gathered it throughout my shift. I used the backside of the sheet to take notes as I talked with doctors on the phone or list complaints or requests from patients and relatives. I kept track of my final charting for each patient by making a forward slant through that patient's room number on this sheet. A backward slant meant I had made a final check of their chart to see that all doctor's orders had been noted, transcribed and signed off. I didn't leave to go home until every one of my patient's room numbers had big "X"s over them indicating my charting and chart checks were completed. When I first started in nursing I used to start each shift with a list of things I absolutely had to make sure I got done (8am medications, 12pm medications, 2pm medications, 3pm report, I&Os, IV levels). After a while I didn't need to actually write the list out anymore. I made sure I had uniforms with large pockets to hold extras of things like alcohol wipes, needles (for IVPBs), a tape measure, a small flashlight, scissors, hemostats, at least one extra pen and my own Tubex and Carpuject holders. Organizing myself was a career long pursuit. It always needs tweaking.

Just a heads up since this came up on a recent thread. Don't take your purse in to work with you. Either leave it at home or lock it in the trunk of your car. Get a small coin purse and never take more than you would need to buy something in the cafeteria and keep it in your pocket. I kept my car keys on a lanyard around my neck under my uniform and they couldn't be seen. I worked in places where people broke into employee lockers to get their purses.

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Kerrigan 06 has 1 years experience and specializes in CVICU.

53 Posts; 1,957 Profile Views

On my unit, our report sheet is printed out before each shift. It's technically called a Professional Exchange Report (I think) but we all refer to them as our Kardexes. They have information such as admitting diagnosis and chief complaint, all doctors consulted, recent and future orders for labs, radiology, nutrition, etc. etc. etc. Usually it's 3-5 pages on each patient. The important stuff is all on the first page.

On the first page of the Kardex, I write a history of stay at the top as I take report, and then across the bottom, under the printed text I write down the systems review that I get from the reporting nurse. After I get report, I take the first page and fold it in half, so I have half a sheet of blank space, and I can easily pull it down to read the stuff that's printed and written.

Once I fold that page in half, I write the patient's room number and last name across the top. Then, down the folded side, I number 19-06 for the hours of the shift.

I go through my MAR and circle the times that I have meds due. I write down labs at the appropriate times to be drawn and circle them. Then, as I perform assessments I write down the time and circle it, then I make all other notes along this page too. As I give meds, draw labs, or document my assessments, I put big check marks through all those circles so I can see what I don't have to worry about anymore! :-)

My Kardexes go on each patient's clipboard, under their VS flowsheet for the rest of the shift.

After 12 weeks in a CVICU as an intern and one week on my own, I finally came up with this system as the best, simplest thing that works for me. I've been using it ever since. I'd tried many other ways to take report and organize time; this just helped me realize that everyone just has to figure out what works for them!

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NursingAgainstdaOdds has 2 years experience and specializes in Med-Surg/Tele, ER.

450 Posts; 5,626 Profile Views

Thanks for the responses - it's interesting and helpful to see how other nurses organize their work. :)

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