I’m smack in the middle of my psych rotation and truly missing the mornings of getting to the hospital in the quiet moments before change of shift, looking up my patient, and jotting down the important details to start off my day. As crazy as the mornings are, and as hectic as it can be trying to track down the nurse assigned to your patient for the day, there’s also something really exhilarating about it all. It’s the start of a new day ahead, loads to learn, and patients who need your help. There’s a buzz in the air that always makes me excited, no matter how nervous I am.
Getting report is actually something I really like doing. Everything is so quick and I like the challenge of having to stay on top of it all, jotting down notes as quickly as the nurse I am working with. I always like to see how the nurses organize their notes. I look at what kind of forms they use, are they standardized, or did they make their own? What’s included on them that I should add to my forms? For med-surg, our school had a clinical form we could use when doing our patient prep, and then complete throughout the day, but I never really cared for it much. When I finally got to my peds rotation, I figured out the things that help me stay organized during clinical. Here are a few of the main components I added:
- First you’ve got your basic demographics: patient name, room number, age, gender, admission date, height weight, head circ (for babies and young children), and allergies
- Admitting diagnosis and past medical history, as well as surgery during current stay and surgical history.
- I like to have diet and activity level up at the top.
- I have a small box off to the side for vital signs. I have two columns, one for 0800 and one for 1200 (use whatever times you will be taking vitals on your shift. It helps me to add a check-off box next to the time at the top of the column. I write the vitals down in the columns, and then I check off the box after I’ve charted them.
- Then there’s a section for treatments and medications. This is where you list the specific things that you need to do during your shift. Anything from what time the wound dressing needs to be done at and what supplies you need for it, to what times they need what meds. If the patient has a long list of meds, I fold the paper in half length-wise and list them there (with room to write important med info and do calculations later).
- Lastly, I have another box that also has two columns in it: one for intake and one for output. Like the vital signs box, I have check boxes next to each place where I&Os can be recorded, that way I can check it off when I’ve charted it.
It’s a pretty basic sheet, but I think that’s why it works for me. I’m not spending my time looking for where I need to write down what information, I can just go with the flow during report. I leave larger margins and use the back of the paper as well, since I write every last bit of information down. If you’re making your own worksheet, my advice would be to know what works for you. Do you write small? Do you need extra space for notes? Tailor it to include what your school wants you to have, and the extra things you think are important too.
Nursing students: What types of forms do you use for getting yourself organized during clinical? Have you made your own? What other items do you have that help you out?