Med Surg Report Sheets Pdf

Med surg report sheets pdf

Every nurse knows what we mean by brain. Not a nurse? It's explained here.

The Ultimate Nursing Brain Sheet Database (33 nursing report sheet templates)

Remarkable ingenuity goes into creating nursing brains. In them, we capture an important aspect of our work: the things we might forget. We use a variety of tools to create these brains: Excel, Word, text editors -- whatever application programs we know best. For consistency, all are presented here in PDF format. From the choices we make about the reminders we find helpful, you can see our perceptions of the cognitive burdens of our work.

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Studying these brains reveals many of our workflow challenges. When we find it necessary to write things down, we are in effect documenting workflow glitches.

The valuable insights this offers gave many of the design concepts used in our NurseMind app.

Med surg report sheets pdf

By Elizabeth Eckard thank you! One patient Many nursing assessments.

Nurse Knowledge Exchange: Med/Surg

Day shift. By a nurse who floats among med-surg, telemetry, ortho, etc.

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One patient Labs. Another handoff SBAR tool -- more general and complete.

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Lots of interesting things to see in this brain! High-acuity unit -- patients have demanding diseases and many co-morbidities. The patient:nurse staffing ratio is The right-hand column is from the backside of the sheet; the nurse folded the page over and lined up the rows for notating vital signs for later transcription to the EMR.

Notations in red are also for eventual charting.

Med surg report sheets pdf

They are crossed out when charted. Lab values of concern e. Relevant medical history Hx is hand-notated.

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Though the hospital has an electronic MAR system, some medications to be administered observe that they are checked-off are hand-notated. Checklist for an outpatient surgical unit Weatherford Regional Hospital, OK Not a brain but a good checklist with a nursing application A memory aid combined with a data-collection function.

Some parts are to be completed while interviewing the patient.

Medsurg Report Sheet

Post-op assessments Pre- and post-op Aldrete score Unlike brains that are discarded after the shift, this one is to be made part of the patient's chart. Classic organization: rows for patients, columns for hours of the day Annotated Nurse uses colored pens to denote, e.

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Structured note-taking for nursing student 6 patients Just the med-surg basics Originally created with Excel. Vrtis, PhD, RN.

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In Italian From a respiratory disease unit Mostly TB and pneumonia cases Frequent decubitus ulcers "Religion" is an important field in a Catholic country. Nursing assessment checklist For the patient chart Also a memory aid for the nurse to make thorough assessments Schmid falls and Braden skin scales Hospital-created, not nurse-created From the Univ.

She has invented her own notational conventions: she circles the room number, underlines the MD's name, and draws a box for each task she might otherwise forget to do and later checks it off when it's done. Thus, her brain is a highly personalized cognitive support checklist device. It omits explicitly listing the tasks for which she doesn't need reminding and is thus designed for her own style of practice.

Another nurse would do it differently.

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A trauma surgery RN's brain thank you, B. Two patients Room for lots of detail You wouldn't use all the fields for every patient, of course; just the ones of concern in each instance. Emphasis on peri-op. An inpatient psych unit RN's brain thanks again, B.

Emphasis on psych assessments. A well thought-out brain from Ashleigh Weeda, RN. One patient Helpful for handoff Complex patients.

The 10 Best Nurse Brain Sheets

For one patient with numerous co-morbidities complex. Up to three IVs. Practical -- though "BS" blood sugar is not generally considered a vital sign, it is grouped with them because it is collected at the same time. WNL ranges for lab values are handily listed alongside the blanks.

Med surg report sheets pdf

Good strategy -- keep the long-term goal in mind at all times. Numerous nursing assessments, e. Thanks again, Ashleigh Weeda, for a clever brain