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Dear Scrubs,I would like to know what makes a good worksheet and how to create my own template. We do not have electronic charting and our charts are not at the bedside so how do I manage to organize the things I need to know, to do and to collect?
Thanks, Darlene
Dear Darlene,
We all feel your pain. I myself created my own worksheet out of sheer want and need. In the beginning of my career their wasn’t a ‘template’ for me to us. I was on my own. Then when I worked in the Trauma ICU they offered an assessment template we could use for report, but it didn’t have much function during the hour-to-hour functioning during your day. Each nurse has their own ‘way’ of organizing their day, their responsibilities, their duties and their tasks. For the most part, a lot of our ‘tasks’ are the same every day and every shift (checking labs, meds, the MAR, etc), while others are patient specific depending on their medical needs and challenges.
I’ve seen some old school nurses use the little drawing to record their patients’ labs, I’ve seen flow sheets used and I’ve even seen a worksheet that is broken down into every hour of your day or shift. I personally believe it has everything to do with the environment you work in. Each specialty setting requires such a great variety of information, skill, tasks, duties, etc. I think we can all agree that caring for 12-15 med-surg patients is extremely different then caring for 2 critical care patients.
So with that in mind here is my suggestion to you for creating your own worksheet: Do some mental imagery. Follow your footsteps through a ‘typical’ day.
- What do you do first? How about report – what information is needed and wanted?
- How many patients (on average) do you care for?
- Each patient and their significant information (labs, history, identification, allergy, etc)
- Medication administration – what do you need and require?
- Are their specific nursing responsibilities you are required to perform each shift (12 hour MAR check, orders, I’s & O’s, treatment record, etc)
- Do you tend to ‘carry’ everything with you in your pockets – or do you have your ‘brain’ on a clipboard?
- Do you like or want a checklist type worksheet to help remind you of meds that are due, tests, procedures?
- What about common phone numbers? Or common dosage calculations?
With all that in mind take all that information and write it out on a blank sheet of paper and try to organize it to your liking. I took all that information and created a worksheet using Microsoft Excel. I chose that particular program since I can customize the size, shape and location of whatever I want within the context of the area of paper. Make the worksheet work for you and customize it for YOU.
For me, I carried around my worksheets. It was feasible for me since I took care of 2 ICU patients. I actually used the front and back of each piece of paper. The front of the paper was for my report and at the bottom of the back of the sheet I had 12 columns for my 12 hour shift. I used the columns to help me keep my meds in order as well as notate when I had labs due, blood sugars, record my I&O, scheduled tasks, etc.
Also, some nurses are big fans of the color spectrum. Using a red pen for the ’emergent’ or important information and then maybe utilizing a highlighter for the pertinent labs or other information that needs to be addressed during your shift.
As you can see your worksheet is up for grabs. You can snip and cut it to your liking. I like to think of it as a ‘work in progress’. Once you start a ‘template’ you always seem to find or discover other things you want to add and eliminate useless information that is just occupying space on the paper.
Best of luck with your creation! I’d be happy to share my worksheet if anyone is interested.
