If you're in the nursing profession, you're most likely one of those people who carry around 4 different colored pens, a bag of highlighters, and a bunch of post-it notes. I remember back in college when I first started my clinical rotations, the best thing that my first preceptor gave me was her brain sheet. It was the most colorful sheet of paper that I had ever seen. So neatly written and every color had meaning.

  There are just too many things to remember about all 5 of your patients. Sometimes we get caught up in a patient room that we forget we have to pass an important medication because we didn't write it down. Maybe after the doctor rounds on your patients, they put in 10 orders that you need to acknowledge, and it just adds to your chaos. When you're not organized at work, you may feel overwhelmed with the amount of orders you have to fulfill to provide optimum patient care and prevent yourself from having any errors.

  That's why I am posting my personal nursing "brain sheet".  I normally place the sticker of patient's on my sheet because it has a lot of their information like their full name, their age, their birthday, and their patient number. This helps me out when I'm passing medications so I always have access to their information to make sure I'm doing my tasks with the right person. I have a small section dedicated to all of my labs and diagnostic imaging orders. There are small boxes where I can just "check off" what that patient can do, such as activities and diet. I have a fairly small box for "orders" because most of my orders have their own box already.

  I have a small section dedicated to PRN medications and fluids because most of the patients I take care of come with these standard orders. On the right side of the page, I have a place for notes from my assessment. I write down what stands out to me so that I remember to pass it on to the next nurse. Then below that, there is a small space for other things to include in report. This is where I would put if my patients needed dressing changes, case management, or if they had surgery or flight notes that needed to be completed.

  I also have a list of personal abbreviations that are not to be used in your actual documentation because they are probably not approved by JCO, so please use carefully.

  There are times when you come back for your third or unlucky fourth shift and you have some of the same patients. When I know my patients pretty well, I use an hourly brain sheet instead to keep track of my tasks. I usually just write in when they have medications due, when they need to go to appointments, or if they have anything else that is time sensitive. This helps me keep track of my hourly rounds. I also use this sheet when I'm working with an LPN because I can keep track of what they're doing for their patients, and it's my way of double checking if they're keeping up with their orders. Very simple to use!

  Hopefully this was helpful! Let me know what you do to keep track of your patients on your busy days. Do you use different colored pens and highlighters? Or do you load up your workstation with sticky notes for reminders? I'm curious!

Happy nursing! Xo,

Lynn