Planning out my day.

The purpose of this journal is to improve myself in the clinical setting. Areas that I need to focus are time management and organization. This is during my senior semester at medical surgical in Valley Med.

Basic plan that I will follow tomorrow.
7:00 before shift report, write names of patients along flowsheet

7-7:30 Focus on listening to the report rather than fathering data from the RANDs. That I can do later after walking rounds. Right down the most pertinent data. write priority lvl of care such as FS and IV access in red. Also mark credit of IV solutions and TIME. For post operative patients, write down what post-op day are they! And when was the previous surgery!

During Rounds: Check IV site, solution remaining and rate running to clarify report. estimate when IV solution will run out!

After rounds: Organize flowsheet and fill out the rest of the information such as Diet, Current Treatment and time (turn q2, oral care q4, VS q 4-8 etc). Obtain Labs from Assistant if possible. Quickly look over medications and plan accordingly. Delagate any finger sticks that needs to be done.

Ideally, I should be ready to access around 7:45-8:00. All assessments should be completed by 8:15. Begin to chart per flowsheet. Start charting before giving medications. Try to obtain vital sign from HSA during or after getting assessment done.

Work on narrative after medication time. During medication administration, find out what meds given, also plan out 0900 and 1300 meds and update flowsheet.


Color code:
Patients name and room#: Red
IV solution and Site: Green
vital signs: blue, Red if abnormal
Prn medication: black, but write last time administered in blue.
Under D/C planning/ goals. Add in abnormal assessment