Designing your brain
Your "brain" is a specialized worksheet designed to make receiving report and monitoring your days' progress more effective. Also efficient, but I aim for effectiveness.
A brain will list the patient's name, age, diagnosis, and doctor. The number of days or admit date helps, it gives you an idea of how much investigating into the patient you will need to do. Report is a snapshot of your patient. It is the diagnosis, history, allergies, plan of care, and specific events that affect the patient. You need to know current lab values, current treatments and diagnostic procedures planned. Are they on tele" If so, what is the rhythm and have there been any arrhythmias?
I want to know how the patient moves, ability to take medications, diet and are they tolerating it? Stuff I will use today. It's not important how they walked a week ago if they have been bedbound since then. A lot of this info can be conveyed in just a few moments, some of it you will have pre-assessed prior to report and noted it.
Specialty units will have other important items. NICU babies have their blood loss tracked throughout their stay. Their diapers are weighed for I&O, and you could even have a "bible" that's used for prepping medications for patients. Adults admitted with CHF need that daily weight, may have a fluid restriction, and Needs a strict I&O. If one isn't ordered, make it a nursing order. You are in charge of your patient's care you own their problems for your shift. Don't play a blame game, just proceed forward with the proper care for each of your patients.
Medications are important. I have a row of numbers signifying the times of day meds are due. I use circles, squares and triangles to signify PO, IV and insulin in that order. If IV flushes aren't listed on your MAR, pick a time to flush IV's if patient is getting at an IV medication at least every 8 hours.
Be aware of your facilities' policy on medications. You need to give them in a timely manner. My most frequent editing of my BRAIN is due to tightening of my practice to enable timely administration of med, and also of dressing changes and other nursing interventions.
Your choice of brain can make or break you. Some facilities have a specific brain, and will dictate what order you will give report and many other parts of your routine. When this happens, their brain becomes a little sheet at the back of my brain that I update briefly to give further report. However, I am in charge of my practice and I design a brain that works best for me. I have adopted a brain if it made sense, or increased my ability to take quality care of my patients. I haven't move that brain with me since I changed my place of employment and that brain didn't translate well when taking care of 5 instead of 3 patients.
Examples of brains/worksheet are available on-line and at Pinterest. Generally, it takes me about 3 weeks to test a new brain. Changes are happening consistently to increase my ability to function in a chaotic environment.