I have heard that some nurses keep notes of their own on what they do on a shift, and some do not.
I kept notes for one shift, being careful not to write down full names, but was amazed at what I had done in the night that was really critical. New coumadin orders, taking calls and orders, calling doctors. Already I referred to one note had the right answer to a question. One of those questions you are asked without being able to pull out the chart to read your note.
Do others keep notes? How? PC, PDA, Notebook (what I use -it fits great on the med cart).
One of the younger mares here keep it all in her head (amazing!) but I am fighting necrotic brain cells and early dimentia (only kidding) so I write things down.
thanks for everyones input into this thread. i thought i would post a update to let you all know how i've progressed.
i bought a cambridge mead notebook at officemax for about three bucks. it is about 3x8 and is spiral bound. this fits folded nicely on the med cart and i use it all night keeping notes (meds out, incidences, complaints etc). i put circles in front of things i need to complete that shift and check it off as i complete the tasks. i date one page for each day, and put 'off' for days i am not in. i note staff on duty, bs checks, and any things else special i need to be aware off.
at the end of the shift i take each item, insure it is done, fill out the reports, and notes as required. it is amazing how much happens when you note things down. from my list i complete the daily shift report which now amazingly has information that is more than 'mrs jones is sick'.
on occasions more numerous than i can count, i have used the book to recall events to 'save my butt'. the detaileddaily shift reports have stopped numerous 'how come you didn't...' comments when i was able to point out to the day shift that the minor details (that come back and bite) are [color=yellow]in writing. i put in yellow important stuff. of course they still don't read it, but the water is there if they get thirsty. i also take a copy of the shift report and staple it in a way that i can unfold it out while still being stapled to the facing page.
the mead notebook has yellow pages with narrow lines and the facing page is printed graph blocks.
with the notebook i started taping neat stuff i collected onto the cover. i also started to write down phone numbers. i started to dread the notebook (which is spiral bound) running out of room, so i took a idea from lifehacker.com and bought 5x8 colored cards which i will put together with ring clips to save all that important stuff (pizza hut number, chinese food that delivers etc.).
one color will be phone numbers, another med cards, another color for something else....i can move pages around and add whenever. if it gets to bulky i just buy bigger rings.
well, that is where i stand. the whole system was less than 10 bucks. (excluding the jetpens.com pens i have become fanatic about.)
i really enjoy hearing from everyone else. a couple of sites i found in quest of tools include jetpens.com (fine point neat pens from japan), lifehacker.com (ideas), notebookism.com (are notebooks a mental illness?), levenger.com (great stuff but expensive).
as an aside, i took a hint from lifehacker.com and kept detailed notes during a inservice, rather than fidgeting, falling asleep, being bored etc, etc. at the end the instructor said she was pleased i was interested and took it so seriously!
covering your butt (for me) is becoming enjoyable because i now know how to win...if it is important enough to do, it is important to remember......thanks to you all!!!!
OldMareLPN
166 Posts
thanks for everyones input into this thread. i thought i would post a update to let you all know how i've progressed.
i bought a cambridge mead notebook at officemax for about three bucks. it is about 3x8 and is spiral bound. this fits folded nicely on the med cart and i use it all night keeping notes (meds out, incidences, complaints etc). i put circles in front of things i need to complete that shift and check it off as i complete the tasks. i date one page for each day, and put 'off' for days i am not in. i note staff on duty, bs checks, and any things else special i need to be aware off.
at the end of the shift i take each item, insure it is done, fill out the reports, and notes as required. it is amazing how much happens when you note things down. from my list i complete the daily shift report which now amazingly has information that is more than 'mrs jones is sick'.
on occasions more numerous than i can count, i have used the book to recall events to 'save my butt'. the detailed daily shift reports have stopped numerous 'how come you didn't...' comments when i was able to point out to the day shift that the minor details (that come back and bite) are [color=yellow]in writing. i put in yellow important stuff. of course they still don't read it, but the water is there if they get thirsty. i also take a copy of the shift report and staple it in a way that i can unfold it out while still being stapled to the facing page.
the mead notebook has yellow pages with narrow lines and the facing page is printed graph blocks.
with the notebook i started taping neat stuff i collected onto the cover. i also started to write down phone numbers. i started to dread the notebook (which is spiral bound) running out of room, so i took a idea from lifehacker.com and bought 5x8 colored cards which i will put together with ring clips to save all that important stuff (pizza hut number, chinese food that delivers etc.).
one color will be phone numbers, another med cards, another color for something else....i can move pages around and add whenever. if it gets to bulky i just buy bigger rings.
well, that is where i stand. the whole system was less than 10 bucks. (excluding the jetpens.com pens i have become fanatic about.)
i really enjoy hearing from everyone else. a couple of sites i found in quest of tools include jetpens.com (fine point neat pens from japan), lifehacker.com (ideas), notebookism.com (are notebooks a mental illness?), levenger.com (great stuff but expensive).
as an aside, i took a hint from lifehacker.com and kept detailed notes during a inservice, rather than fidgeting, falling asleep, being bored etc, etc. at the end the instructor said she was pleased i was interested and took it so seriously!
covering your butt (for me) is becoming enjoyable because i now know how to win...if it is important enough to do, it is important to remember......thanks to you all!!!!
primum non nocere