A brain sheet, I consider it an essential tool for each shift I work. I made the original and continued to make small changes to the brain sheet, little tweaks to make documenting that much easier day-to-day. One question, what is a brain sheet? A brain sheet is a template that notes, and assessments are kept in some sort of organization. But why are these templates a necessity in caring for patients utilized by the nurse and the student?
#1 Organize patient information
A brain sheet is a template to be filled in by the nurse or student. An area for each body group, allows notes for assessments and notes, for instance, you hear crackles on the base of both lungs, this would be found under the respiratory section. The organization can be in whatever order there is no right way, the information can also be specialized depending on the unit. A telemetry unit will have a more in-depth area of cardiac, labor and delivery will have a space for the baby and a more extensive focus assessment for the women. When using the same sheet day after day jotting down the information in the same area becomes second nature, it’s easy to document and easy to find.
#2 All notes/orders/observations are with you
The brain sheet, at least for me, is a sheet of paper that I fold in half. My template allows information on the front and back of the fold and fits perfectly in the pocket of scrubs. At any point I need to refer to the report, it’s with me in my pocket. Anytime new information is given to me either by a physician, another nurse, patient or family I can write down the data or order for future use or to be added to an assessment later.
#3 Easier to give a report
When all the information is right in front of you and organized, it is much easier to give to another nurse report on patients. Especially for new nurses, use some type of brain sheet; this will provide you with a guide to use when establishing a method for giving a report. The page can be placed in any order, going seamlessly down a list of assessments regarding the patient. Hitting key points each time you won’t miss vital information about the patient. This will make a better report and better communication between nurses and other staff.
The use of a brain sheet is a crucial tool used for each shift. I did make my own sheet when something happens, and I don’t have the sheet, I feel lost at work. It helps keep information neat and accessible, other nurses will appreciate the organize report and ample information provided in the page, and physician will agree to the promptness of the information when asking a question regarding a patient. A brain sheet is an indispensable tool.