Tools, Notes for YOU to CYA

eldragon · Mar 21, 2008

I keep notes written down on a sheet of paper that consists of who gets pain medicine, and why and what time;

any meds withheld and why;

any meds not given because there's none left, waiting for pharmacy, etc.

I keep everything on one sheet, usually front and back is filled after one shift - and shred it on the way out.

JeanineLPN1984 · Mar 22, 2008

I use a clipboard with a shift report sheet. Like eldragon I write all that stuff down, blood sugars, MD calls orders, v/s or anything unusual.

I give it to the oncoming nurse during report, so she has a quick reference guide for herself.

robinbird · Mar 22, 2008

I use a sheet I designed myself to log vital signs, blood sugars, etc. The sheet has a list of systems- Mental status/Neuro, Cardiac, Pulmonary, GI, GU, muskuloskeletal, integumentary. Under those topics I jot down key words like: neuro-A&O x 3, cardiac-S1/S2, regular, pulses +2, Pulmonary-crackles-bases, diminished throughout. I also have a list of tasks that need to be completed every night and I cross them off as I do them. There is also a section for History that I fill out when I get time throughout the night. I use a sheet for each patient, fold it up and keep it in my scrub shirt pocket, so I can pull it out to write notes or as a reference. I use these sheets to give report in the morning, and have all the information I need to give a good report.

I usually leave the sheets in my locker to refer back to on my subsequent shifts. At the end of my three days I drop all the sheets into the shredding bin.

I have tweaked this sheet :typing every few months over the last 18 months so now it works really well for me.

Robin:redbeathe

imanedrn · Mar 22, 2008

I use a sheet I designed myself to log vital signs, blood sugars, etc. The sheet has a list of systems- Mental status/Neuro, Cardiac, Pulmonary, GI, GU, muskuloskeletal, integumentary. Under those topics I jot down key words like: neuro-A&O x 3, cardiac-S1/S2, regular, pulses +2, Pulmonary-crackles-bases, diminished throughout. I also have a list of tasks that need to be completed every night and I cross them off as I do them. There is also a section for History that I fill out when I get time throughout the night. I use a sheet for each patient, fold it up and keep it in my scrub shirt pocket, so I can pull it out to write notes or as a reference. I use these sheets to give report in the morning, and have all the information I need to give a good report.
I usually leave the sheets in my locker to refer back to on my subsequent shifts. At the end of my three days I drop all the sheets into the shredding bin.
I have tweaked this sheet :typing every few months over the last 18 months so now it works really well for me.

I do something very similar.

I use a binder now (because I've realized I forget EVERYTHING if it's not written down... so I keep it ALL in there!) with a separate sheet for each patient that I place in front of their Kardex.

On the left of the sheet, I circle med times, write down abnormal labs, and write down important things to do throughout the shift.

On the right side is the physical assessment data (like yours). I write what the night shift tells me, then add my own or confirm that what they told me is still present. I also include IV fluids & accuchecks.

Behind that page, I have another with my shift from 08-18 with vitals at 4 hour intervals. (I include more if it's necessary, i.e., for BP meds or a change in status. I also will include times for procedures, i.e., "stress test: 1051-1147" or times that pain meds are administered, i.e., "0903, lortab 7.5 mg, pain 8/10, head" so I can document them when I have time.)

I review the Kardex in the morning but don't use it much throughout the shift. (I wish I could be like those nurses who scribble down EVERYTHING on it and can somehow make sense of their notes at the end of the shift!)

Behind the Kardex, I keep copies of all orders - so I can make sure procedures/tests are in the system & ordered, meds are in the system & on their way up, and that I ultimately follow up on them.

I'm so obsessive that my mind goes crazy trying to remember everything. If I don't write the important stuff down, I forget most everything :uhoh3:

CABG patch kid, BSN, RN · Mar 22, 2008

I have to wonder, are you referring to keeping notes like after the shift is over to take home and keep, or just during the shift? Because if its just during the shift, I think most if not all the nurses I work with all keep notes of some kind to keep track of several things (you can't always chart the second after you do something).

Now if you're referring to notes that you keep at home, like a journal, I'd be really careful about that one. If you are ever taken to court for anything (god forbid) one of the first things your lawyer will ask is if you have any notes or a journal at home pertaining to the case. If so, he/she will probably tell you to destroy it, lest it be used against you in court. Everything to CYA in a lawsuit should be in the patient's chart, that's why documentation is so important.

Sorry for the tangent but the importance of these "notes" was stressed to me. If it's important enough for you to write down on your personal report sheet, most likely it's important enough to be in the patient's permanent record.

OldMareLPN · Mar 22, 2008

"If so, he/she will probably tell you to destroy it, lest it be used against you in court. Everything to CYA in a lawsuit should be in the patient's chart, that's why documentation is so important."

Well I think you are on the money, actually everyone was. Notes to keep during the shift (I like creating a form that works) which also can be used to make sure everything is charted correctly by the end of the shift.

Gonna work on a form, and one I can give to the oncoming shift. Perhaps there is a way participants can upload theirs somewhere on this board?

OML, :banghead:

TheCommuter, BSN, RN · Mar 22, 2008

I jot down info in a composition notebook throughout the course of my shift. This also serves to keep me organized and less "scatter-brained."

CABG patch kid, BSN, RN · Mar 22, 2008

I think there are a few threads on here where people have uploaded their "brain" sheets, I'm just too lazy to search around right now

Also, what I did to develop my brain was to keep notes on a blank piece of paper (a whole sheet per patient for me), did that for my first 2 weeks on the job. Then took a few filled in papers home and made a template. Hope that helps :)

sassynurse78 · Apr 6, 2008

I am so obsessed with lists, I write everything down on lined paper starting at the top and then can check off what i have done, what needs done or what to pass on, and I never check off anything until it is taken care of.

nckdl · Apr 8, 2008

I keep a log of all the stuff I have to do, because even though I am young in age, my brain feels old. :chuckle I get interrupted so many times a day and usually during med pass, so I right it down to accomplish later. I do take it home and keep it usually a month then shred them. They have no names on it, just numbers and some pertinent things I receive in report. Last week I was called by a higher up that I didn't do something and I was told in report about it. I was able to pull it up and prove that I wasn't told anything about it. Of course the main reason to keep notes is to make sure everything at the end of the day is charted and all paperwork is filed properly to CYA.:wink2:

vivibonita · Apr 11, 2008

Also, what I did to develop my brain was to keep notes on a blank piece of paper (a whole sheet per patient for me), did that for my first 2 weeks on the job. Then took a few filled in papers home and made a template. Hope that helps :)

Do you have a copy of that template that you could email to me? I will appreciate it.

Peace