Do you use a clipboard? Do you flip pages, or do you write everything on one side of a sheet of paper for shift? Do you pre-print a special format? How many PT's do you fit on a sheet of paper? Are you an impromptu sheet maker? Have you ever scoffed at another RN's sheet?
For each shift, I use one sheet of the thin engineer graph paper you get at the bookstore for a penny a sheet. Then I fold it so I make 4*8=32 label sized boxes. The floors usually have no more than 28 beds, so I have a spot for everyone. I'm addicted to the .5mm pencil with the soft graphite (4B). Then, for each PT in a box, I have just enough room for rm#, name, and RN name plus 5 spaces under it for vitals, and 4 columns after that, per PT, for add'l vitals input, output, cbg. It took me 7 months to develop the best way for me to write down stuff in a nursing environment. This way, I can have a hard copy of what I'm doing as I put it in echart AND let the RN's know exactly what I do AND make it easy for the RN's to do their charting of vitals from my clipboard.
It's cool some nurses w/5 PT's, use one sheet and circle hours for meds or IV's, and I can only dream about organizing stuff an actual nurse has to note and record. Some RN's just use a folded sheet of paper in their pocket. I guess it depends on what your doing too.
Short of wearing a backpack, how do you manage the clipboard in patient rooms?
I use a plain $1.00 clipboard from Walmarts and have just a single thin sheet of graph paper folded. Again the paper is "onion paper" with light boxes at 1 sq mm intervals. I love this with the .5mm pencil. I wedge that under the keyboard of the mobile echart and vitals station. Then any of the RN's or Doc's can access it and understand what is in echart.
As far as my clipboard being a fomaite it doesn't leave my site, and I wouldn't be placing it on sterile surfaces. I usually go for the window ledge or the chair when I place it down, if needed.
Also, I get into the symbols. like triangle means trnsplant (red)and circle means isolation (blue). My own personal ones are: connect a cube to fill in CBG's, and i'll make a double lined column if vitals are needed to be taken again. There is no other way for a CNA to be organized if expected to accurately record I/O and CBG stat, or rm #'s....forget it :-( I'm sorry
My clipboard is from "kwik klip enterprises" and has preprinted essential info all over it, including UA values, CBC norms, IV infusion rate calc. tables, 'lytes, abg norms, acidosis vs alkalosis metabolic vs respiratory cheat sheet, injection info, f to c temp conversion chart, breath sounds descriptions, Glascow coma scale, common respiratory patterns, and daily pt. assessment info.
Where did you find this clipboard, if you don't mind my asking?
I've had a couple of patients in pediatrics who pinch and have drawn blood. It's not like a two fingered pincer grip, more like grabbing a handful of flesh, say around your forearm, and diging in with their claws. (Is there an easier way to state this?)
So far, I have been able to peel back their fingers. I've been thinking that if I couldn't break a grip, perhaps I would step back so that the patient would risk losing their balance if they went with me. I would be there if they started to fall, but I am hoping that they would release their grip and stand back.
We always write it up, too
One of these patients was visitied by a pro football player with a new Super Bowl ring. He grabbed this fellow "there". Downed by an 11-year old in halo traction. I didn't witness the event, but did note that the player was not on the field in the next game.
I have the storage clipboard shown in a previous post. It also has a calculator on the top (not shown in pic). It won't hold everything you want to put into it Mario.... for instance if it has my drug book in it the steth won't fit unless I really cram it and twist it and then force the lid down.
also, I have a question on patient confidentiality. You all are stating that you put the patients name and room number on these sheets. This is great if only used in the hospital for charting, but I am a student so If I wanted to use the information for my careplans, I would be in big trouble for that... too much ID on the paperwork taken outside the care setting.
Yeah - they barked at us for copying MAR's and admit historys and care plans...what are you gonna do?
What I write on my clipboard is "hospital property." i have no intention using that information. I discard the clipboard entries at the end of shift. I can't think of an example of when a person would want to access PT data except for legal reasons.
Yeah - they barked at us for copying MAR's and admit historys and care plans...what are you gonna do?
What I write on my clipboard is "hospital property." i have no intention using that information. I discard the clipboard entries at the end of shift. I can't think of an example of when a person would want to access PT data except for legal reasons.
Yeah - they barked at us for copying MAR's and admit historys and care plans...what are you gonna do?
What I write on my clipboard is "hospital property." i have no intention using that information. I discard the clipboard entries at the end of shift. I can't think of an example of when a person would want to access PT data except for legal reasons.
Do what we do : invest in a black sharpie. Mark out all the ID on the patients. And when you make the homemade sheets up, don't have a place for the patients name... we use initials. That has worked for our class so far, though whether that will pass the new HIPPA (I think that is what it is called) laws I don't know.
I use the folded paper stuffed in the pocket technique myself, but have longed for a clipboard. I never have figured out what to do with the clipboard though. The written information is needed when I am in the patient's room, but there is no "clean" place to put a clipboard down. I hate to pick up and drop off germs from room to room on the back of my clipboard.
Short of wearing a backpack, how do you manage the clipboard in patient rooms?
we have chart racks outside each pt's room. I usually can find a spot to put the clipboard down somewhere in the room (NOT on the bed)--and I put a paper towel down first as a barrier.
If it's an infectious patient in isloation, I leave the clipboard at the chart rack, do my assessment, write it on a paper towel, and transfer it to the sheets and throw away the towel when i get outta the room. I do it that way because i do all my assessments first, and if it's hectic and I have a lot of pts, I won't forget those lil details that jog my memory like, "L arm redness & +1 edema s/p iv site d/c."
On the outside of the clipboard, i have taped my freq. called # list: supervisor, pharmacy, lab, & respiratory. On the inside, I have a couple reference cards (you know, those laminated deals that give you lab values, pupil size and such), a couple of pens, scissors, a sharpie, a couple of alcohol swabs, a couple of gator clips== you know, little things that you don't wanna hafta run down the hall to get at 3 am when something needs doing fast. Oh, and a 4X4 always comes in handy for when you find that confused pt wandering in the room with the #16 IV pulled and bleeding everywhere....
My scope stays on my neck at all times unless i'm using it. I don't carry a drug book with me, because usually, if I have to look up a drug, that means I have to pull a drug, which is why i think it makes more sense to have your drug guide up near where the meds are.
Sorry this is a little long, but it may give you an idea or two-- your information collection is a very individual thing and everyone has a different way of doing it..... no way is really wrong, you just want to achieve the most effective, efficient method possible.
'cause lawd knows, we don't have much time to do all this stuff.
Actually, the only notes I take have to do with small tasks I need to remember. I've always just take mental "notes" when I'm listening to report. Of course, working in ICU I only have to remember stuff for one or two patients...
Actually, the only notes I take have to do with small tasks I need to remember. I've always just take mental "notes" when I'm listening to report. Of course, working in ICU I only have to remember stuff for one or two patients...
oh geez, just rub it into us poor ms/tele nurses, whydoncha??? :chuckle
mario_ragucci
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