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how do you keep your work between each patient organized ?

i want to learn how i can keep up with each patient's information #nursing #nursing-education #nurse-practitioner #healthcare #hospital-and-health-care


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Lisa’s Answer

I always keep notes to myself. If you work in a hospital or skilled nursing facility you will receive "report" from the prior nurse who will tell you about your patients. I always had a list of the patient why they were in the hospital or facility, and any abnormal test results or problems that I needed to be aware of for my shift. You also have the medical record to use as a reference. That ideally (and legally) will have test results, notes from anyone who sees the patient (therapy, doctor, discharge planner, home care agency) any orders that have been left to follow medications times treatments, etc. It is always frightening at first, but with time you will learn your own "style" to remember the patient. I work from home as a nurse, and I don't ever see my patients in person. So to help me, when I talk to them I will frequently keep a Cheat sheet that may have something like the dog's name, favorite sports team, or something individual to help me remember. I have been a nurse for over 30 years and I still use notes to myself. I think it becomes an individual process that you have to develop that works best to you personally. I think that others can give you suggestions, but ultimately you know yourself and how you remember best. Sometimes it is a color code system Red for immediate need, Yellow for within the next 4 hours, or green before the end of your day. I hope this helps. Good Luck If you are a nurse, it is the greatest and most challenging profession there is in healthcare (in my opinion). :) Lisa



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Karyn’s Answer

That's a really great question because depending on what specialty you go into you could see as many as 20 patients a day & that is a lot to keep up with. The good news is, wherever you work there will be electronic systems & people in place to help you keep them straight. The best way to help the staff and yourself is to do your documentation as quickly as possible so you don't forget anything you discussed with the patient. The most organized physicians I have worked with dictate their encounter after each patient. The worst wait until the end of the day or weekend to do all of their notes but by then it is very hard to keep all your patients straight. This also causes other problems down the line for billing & if a patient needs surgery. I hope this helps!

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Estelle’s Answer

Electronic medical records has made this easier in general, but the best nurses I know keep notes with them about each patient. As you become more proficient at your job, you will need to keep more abbreviated notes because the work will become more fluid and make more sense. Good luck to you!

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