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A visit to various hospitals throughout the country would reveal vast differences in charting and documentation. Although many large hospitals have adopted computer charting and order inputting, this new phenomenon is only a couple of years old, and many hospitals still rely entirely on paper.
In our profession, it is common to find set standards of practice but very few standards of documentation. Some paper charts are found at the bedside, some computer charting docking stations are clustered at a central nurses station, and some units even have a kardex that acts as a patient summary at the bedside or outside the door with the full contents of the chart stored elsewhere. Aside from the location/nature of the charting itself, even within a single facility you would find that each and every nurse has her own unique style of charting, some more detail-oriented than others. As with any system in place at a hospital, people can argue that one way is better than the next.
The most important, and most personalized, material aspect of a nurse’s day is her “brain.” When I first started as a new graduate, I heard a seasoned nurse ask if anybody had seen her brain. It took me weeks before I realized that this nurse wasn’t implying that she had lost brain matter, or lost her mind for that matter. Instead she had misplaced the most crucial contents of a nurse’s workday- her patient notecards. Now, like previously stated, no two forms of documentation are the same. However, every nurse has a “brain” that they rely on throughout the workday that acts as a mini patient chart, a bitesize day scheduler, or even tiny to-do list. A Scrubs reader recently was seeking out opinions on what type of nursing worksheet is most effective. In hopes of gathering an educated response to this inquiry, at change of shift one morning I scoured through the nurses station peeking at everyone’s “brains,” trying to decide which was indeed the most effective. Funny thing is, the realization struck me that ask any nurse what type of worksheet is most effective and she will most definitely pull out hers.
Contents/types of nursing “brains”
Index card– various shapes, sizes and colors. I have even seen nurses choose specific colors based on acuity of their patients.
Kardex– 8×11 sheet of paper with details of diagnosis, lines, drains, labs, diet orders, activity restrictions, wounds, etc. Acts as a mini patient chart that the bedside nurse can tote along throughout her workday without having to repeatedly gain access to the full chart.
Some nurses prefer to fit all of their patients on one sheet of paper that they can fold up in their pocket, some prefer to have each patient on a different sheet of paper so as to keep them separate.
MAR record- Nurses will print the MAR record on each patient and make notes in the margins regarding plan of care for the day. This ensures that no medications are missed in translation.
“To-do” list– I have seen brains that have boxes that can be checked off once tasks are completed and some that have boxes for each hour of the day where the nurse can write in medications due and procedures for specific hours.
As for me? The perfect brain is a 4×6 index card, a separate one for each patient, with information placed strategically on each line. Name, DOB, weight, allergies, and attending physician on the top. Diagnosis and pertinent medical history, along with events of the last 24 hours and expected procedures for the day on the left side. Physcial assessment, diet orders, lines, drains, etc on the right side. Medication schedule by hour on the back along with any other pertinent social or extraneous information that will impact care.
In reality, I have failed in finding a definitive answer to our reader’s inquiry. But my recommendation for a new nurse to find the most suitable “brain” is to use trial and error, borrow ideas from fellow nurses and see which method works best to keep your day organized and chaos at bay 🙂
