That was until now. Now I totally understand how devastating losing my "brains" is. I have also learned that no nurses keeps hers exactly like another nurse. From organization to pertinent information, every nurse has their own unique way scribbling it down to fit on one sheet of paper, making it very apt that we call these papers "brains". Not to mention every department requires a slightly different brain sheet, you'll notice a Tele nurses brain looks nothing like an ICU nurses brain.
When I was first getting started it was one of the things that required a lot of trial and error for me to get "just right". In the development process I looked at how the other nurses around me scribbled down their information, paying close attention to how they organized it and what info they kept and what they did not. Now I have a system that works for me pretty well, and I figured I'd share.
So let's start with a brains for Telemetry.
Obviously this is a HIPPA-ized version of my report sheet, but it IS a real one from my last trip to Telemetry.
It was made on a single sheet of paper that was folded in four so that it can be folded and fit easily into my pocket for quick reference.
My belief behind my brain is that is should contain only relevant information but at the same time I should be able to know everything about the patient in just a glance to my brains.
So let's go over a few of my organizational tricks really fast before I go in depth into my brain.
The first thing I do is color code my brains, notice the red and black pen. Basically the black pen is your basic information, major systems information, vascular access, labs etc. The red pen is important information that you want your eyes to fall on like drug allergies, medical history and diagnosis, and things to do like blood glucose checks and meds to give.
Second thing to do is decide what information is relevant to me and my treatment of the patient. On a Telemetry ward it's handy to know what telemonitor the patient is assigned. Generally I take down information by exception, meaning I only write down what is abnormal with my patients rather than everything that is going on. I always right down what lines the patient has, where they are and what is running through them this way I know who is going to have IV's to hang. Also if the patient has any procedures going on like dialysis it's important to note what days they generally have it done on in case the Doc wants to know.
Third thing I do is review what is on the To Do List for the the shift and jot it down (in red) so I know what has to be done with each patient. More importantly this gives you a picture of what your night is going to look like as a whole and gives you the ability to prioritize. By doing this I can now look at all the meds that I have to give on this shift and know that Patient #4 doesn't have any meds due until 2300 so I can leave them to last for med admin and get to the other folks who have earlier meds due.
To help sum up everything I've said
here is what my brains for just one patient looks like.
I hope this helps and makes it easier for you to summarize the whack loads of information that we get as nurses down into a small concise picture of what is going on with your patient.
If you are looking for some more templates for brains
has a great set of brain sheets with a number of different layouts for different specialties
Do you have any tips that you would like to share?