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Check out the screen shot of this worksheet
I was actually just about to start typing one up for myself, and saw your post. I am starting my med/surg clinicals and will have 2 patients. So, if anyone does have ideas I am all ears (eyes)!Thanks!
I'm going to attach a worksheet or two I used as a student for clinicals; maybe you can use it, too?
For the "Shift Worksheet" one, I used it for med/surg clinicals and just circled times meds were due, jotted down v/s q4h, and notes next to each area of assessment. I could get four patients on one page this way, just the basics. Where it says "PA", I would note if there was a PA to follow pt (one hospital almost always had a PA for each pt, another never did).
For "A.M. Pt Assessment", it was one I got from my instructor that I modified to suit me better. It had everything she was looking for, as I recall, in a format that made sure I covered the whole assessment.
Feel free to use these as you need....these are the student ones I used, not the one I'm using now, as I believe the student ones are more what you're looking for at this point. Best of luck to you!
When I first started I developed several different sheets to keep me on track, since each pt is different and needs different care, I went back to the basic hand written form. I take a blank sheet of paper and draw three colum across and six down, in the first col, I write the room, pt, and dx, (writting small) to save room to add. I place diet, gluc times, and any other info I need at a glance when pts call out. In the second col, I write any thing that needs to be recorded mainly I and o, Iv__________, foley ________, PCA _________, tubes, ect, this is where I wriite the readings as I go from room to room. The last col, I write medication times such as 2100, 2400, 0300, ect, this way I know at a glance when meds are do on each pt. I also write times of dressing changes and other to do list type items. I take this sheet into report so I have all the information of what I did that night to pass on.
This works well for me.
bklynborn
196 Posts
Hi.being new to our hospitals medical floor I have noticed that there are several creative worksheets in use..................since I need to find one that works for me I was hoping some of you might offer some tips or even forward me copies of what works for you????? I understand that I will be responsible for up to 5 pts a shift and that hte usual pt load is 4.......thanks for your help:confused: