[[Notes]] - Topics: [[Organization]] - People: Sarah (RegisteredNurseRN) - Source: https://www.youtube.com/watch?v=lNwRvKaNsGc --- ## Summary - [[Systems can be cultivated during times of calmness. Systems are tested during times of crisis.]] - Find the most effective way of doing something, then standardize it. Standardize that practice for yourself and for your team. - Use templates to encourage protocol. - Consolidate information into intentional sections. - [[Make things easy to find, hard to forget, and impossible to misunderstand]]. ## Notes ### Nursing and charts - Charts contain a lot of information. It can feel overwhelming. - Nurses use charts to develop a care plan for the patient. - Every hospital has a different system. ### How to organize - Create your own report sheet template. - "They allow you to have a **quick reference** for when a doctor asks you a question". - keeps patients separated. - Keeps track of tasks. A place to add notes. - Shred the sheet at the end of the shift to comply with HIPAA. ### Ways to master - Find time to understand and practice charting. - [[The worst time to learn how to swim is when you're drowning]] - Spend time with the material. Cultivate an understanding for how the chart works and how other people work - with patients and with each other. - Learn what's vital to note. Learn how to ask the right questions to report. - Hospitals typically offer courses or learning material on charting. ### What's important - Consolidate information into intentional sections to make it easier to locate. - Standardize that practice. - Being organized and effective with your notes is critical to the well-being of patients, which is made more challenging by the extended hours of work. - [[Systems can be cultivated during times of calmness. Systems are tested during times of crisis.]] - History and patient section. - Filled up by the physician which includes a patient complete history of health and most importantly what the doctor plans on doing. What the regiments are to start, who to consult, and what procedures others are going to order. - Other sections include diagnostic testing results as well as lab work. ### Helps you do your job - Vital signs and flow sheets. - Nursing notes includes the care plan as well as the daily plan. You are also able to see the notes from the previous shifts. - Doctor's orders are updated asynchronously by the attending physician(s). It is also a place to see future orders. - Doctor's notes drives what you're going to be doing that day as a nurse. - The medication intake system also drives how your day goes and how you're going to plan your care plan. ## Original ![[Charting for nurses. How to understand a patient’s chart-1.jpg]] ![[Charting for nurses. How to understand a patient’s chart-2.jpg]] ## Sample nurse report sheets ![[Nurse-Report-Sheet.jpg]] ![[Nursing-Report-Sheets.jpg]]