Brain sheets are great tools that can be used by the nursing student or the nurse. Most nurses have their own method of keeping notes on patients, similar to a brain sheet. As a student, you make your own brain sheet based on your weekly clinical paperwork. The brain sheet is an excellent way to organize notes and documentation.
#1 Know what you want
A brain she has some different possibilities as far as layout. Google or Pinterest are filled with images of other brain sheets. Research the different formats available, is their one you like over another. One consideration, the number of patients that are being cared for each shift. This will play a role in deciding a format. Are you a student with one or two patients? The sheet I use on a Medical-Surgical unit with six patients has three columns horizontal. This allows three patients on one page. Format possibilities are endless. I’ve seen the use of columns allowing one to six patients per sheet. These columns can also be horizontal, and information can be on the page. Find a blank or basic sheet in the format that you like the most, print out and use your next shift or clinical.
#2 Every unit is different
Every unit is distinct. The floor that the nurse works on will make an impact on the sheet in several ways. The number of patient and the type of focused assessments depends on the unit. A nurse on a cardiac or telemetry unit will go more into depth into ECGs, heart sounds, and other cardiac measurements. Meanwhile, a neurology unit would focus on the neurologic exam. Not all brain sheets will work as well for every nurse and every floor.
#3 Start to use a blank sheet and make notes
The best thing at this point is to start using the sheet. By using it, you will notice specific documentation that continues to find itself on the sheet. Add notes often to where you need more space or if there is a need to move something around to make it work better. An example, I have a table for vital signs. The program used on the hospital list the vitals in a specific order. I mirrored the structure on the table. Each week with these particular notes go back and make changes to the blank sheet. By making these small changes to the sheet each week, the brain sheet will begin to take on a personal look that is your own and start to function more efficiently each week.
#4 Make one on your own computer
If you’re like me, you like lines, a distinct place to put information. I must admit I’m particular when taking notes and I want a well-structured design. I also like my sheet neat and organized. I’ve seen the number of people use a handwritten photocopy each shift. These decisions are entirely up to you, and everyone has their own opinion and particulars. I started my sheet in Microsoft Word. I created areas and boxes by making a table with three columns. Increasing a space by either merging cells or pressing enter to increase height. After a week or two make additions that are particular to your unit and documentation. For instance, on my floor when someone is on telemetry, the box number is documented. An area in cardiac was added to include the box number, serial number, and patient’s rhythm recorded.
#5 Trial and Error
Once you have a format of a brain sheet and you have been using it. What helped me was having a printed version that was only used for notes regarding changes. This is placed on the bottom of my clipboard. This was where I would compile all my notes, either in bullet format or drawn on the sheet. One example was the documentation of ins-and-outs and weights on my shift. I started to etch a table and notice it was every shift. This soon found a permanent place on my brain sheet.