How to Stay Organized as a New Nurse

How to Stay Organized as a New Nurse

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Learning how to stay organized as a nurse can be challenging, especially as a new nurse

Use these 7 Nursing Tips on how to stay organized to help keep you organized and efficient!

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How to Stay Organized as a Nurse

The learning curve as a new nurse is super high, and we could all use some tips on staying organized.

There is so much to remember when it comes to all of our patients, and we are expected to know all of their information and often have to recall it in high-pressure situations.

Organization as a nurse takes time and experience, but if you are diligent – you can become that organized nurse that you’ve always wanted to be!

1. Get There Early

On my first day as a nurse, I arrived at 6:50 am bright and early to my new Med-Surg unit – excited to make a good impression.

I walked over to my preceptor and she looked at me and said “you’re late. I’m already getting report. You’re expected to be here at 6:30 tomorrow”.

I had NO idea that I needed to get there so early? But why?

One major tip on how to stay organized as a nurse is to adequately prepare and “read up” on your patients. This takes time, which may mean needing to get there early.

This is especially important on Med-Surg units when you will be caring for multiple patients at once.

Most facilities will have some type of print-out with the patient’s medical information on it including their attending physician, allergies, diagnoses, and their medications.

Using these sheets, look through their medical record for information like:

  • Why they’re admitted and what they’re being admitted for (Look in the H&Ps)
  • Their vital sign trends
  • Their IV access (gauge and location)
  • Their active orders (diet, activity, code status, etc)
  • Any other information you deem to be important

If your facility doesn’t have these printouts, or if you prefer to use your own – bring your own!

I always made my own that I would use. You can sign up for my free patient organization sheets here.

Now when you get nursing report from the previous shift, you will have some baseline information to go off of.

Make sure to have space to write down important information that the previous shift’s nurse gives you.

I would say as a new nurse it is important to get there about 30 minutes early to start writing up on your patients. However, as you gain skills and become more proficient, 5-15 minutes early will likely suffice.

Also, understand that you are not getting paid for this time. Being so – it is not mandatory, but it will help your shift go more smoothly.

Quick note: What worked well for me was briefly reading up on my patients, looking at their vital sign trends, and their main admission diagnoses.

I would get report, assess each patient and pass meds, and then when I got time later on I would read more deeply into the H&Ps, writing down important information to pass along to the next shift.

2. Learn To Prioritize

Learning to prioritize is essential in figuring out how to stay organized as a nurse.

As nurses, we have so many tasks that we need to accomplish, and figuring out which order to do them is can mean the difference between life. That seems extreme, but sometimes can be true!

First, prioritize which patients you should see first.

A patient that has more unstable vital signs or more serious diagnoses should be bumped to the top of your list.

You should probably see the patient with CHF on Lasix and oxygen before you are seeing the patient with a broken hip who was recently medicated and is comfortable.

See those who are “more sick” before those who are “less sick”.

This is because those who have more serious diagnoses are more likely to decompensate.

Seeing them quicker can mean faster intervention and prevention of poor outcomes.

Also make sure you are prioritizing your tasks.

Sure – everyone needs to be charted on and their care plans completed, but making sure medications are administered in a timely manner is likely more important.

In the hospital – unexpected situations are inevitably going to occur.

Maybe you need to take a quick pause on your charting to go give pain medication to a patient who is requesting it.

Assessing a patient who is hypotensive takes precedence over giving your other patient their bedtime pills.

Learning to prioritize and being flexible will help you learn how to stay organized as a nurse, especially within the hospital.

3. Make Lists

In order to prioritize tasks, you actually need to know which tasks need to be performed.

As an experienced nurse – this can become second nature. However, as a new nurse – you are prone to forgetting or missing something.

Since it is so new, you need to write it down to make sure you do everything correctly.

I would always have checkboxes on each of my sheets for each patient. These checkmarks would include:

  • Assess
  • Chart
  • Medicate (with times ordered i.e. 9pm | 12am | 5am)
  • Care Plan
  • Rhythm Strip Interpretation

As a new nurse, you will inevitably be task-oriented. This is unavoidable and ensures that all of your tasks get done.

Once you gain experience, you will improve your critical thinking skills, and completing your tasks will become second nature.

4. Real-Time Chart

I know I said to prioritize medication passes and urgent assessments over charting – and that holds true!

But something that made me an efficient nurse is real-time charting!

Essentially this means right after I saw my patient and assessed them, I would park my computer-on-wheels right outside their door and quickly chart my assessment.

This only takes about 5 minutes while the assessment fresh your mind.

As a new nurse, you will forget to assess certain things that are important to assess! If you real-time chart, you can easily just walk back in and complete your assessment.

This does not take as much time as you think. If you have 6 patients, that’s only about a total of 30 minutes of charting.

Anecdotal Note: I would start assessing and charting my patients after getting report around 7:30, and move onto the next patient.

 

Once 8pm hit, I could medicate my patients for their night-time med pass. I would assess, medicate, and then chart.

 

Finally, I would double back on the initial patients to medicate them. This means all my patients would be assessed, medicated, and charted on by 10pm.

 

This leaves the rest of the night for any admissions, to hourly round on your patients, answer call bells, and perform the other tasks needed like care plans and reading up in their H&Ps.

Related Article: Top 6 Charting Tips for Newbie Nurses

5. Investigate Before Notifying

Another aspect of how to stay organized as a nurse is doing proper investigation before notifying a Provider.

This improves the communication and ensures the patient gets what they need. It can also help avoid a negative interaction with a Provider – which we all know can put a damper on the shift.

Learning to organize your thoughts and relay your concerns to the Provider is not inherently easy. The added pressure doesn’t help!

Make sure to investigate any anticipated questions they may ask. Some examples include:

  • If you are calling about high blood pressure, make sure you write down the BP trends, what they are taking for blood pressure, and if anything had needed to be given for high BP before.
  • If you are calling for additional pain medications, make sure you have an adequate assessment of the pain (new or chronic, location, radiation, etc), what they are currently getting for pain, any PRNs or previous medications given for pain, etc.

Make sure to include any recommendations you may have. Make sure to use a proper SBAR format.

“SBAR” always left me a bit confused and wanting more, so I made up an “IMSBAR” format which you can read all about here!

Related Articles:

6. Stock Up

Learning how to stay organized as a nurse also means always being prepared for whatever can happen. This means having the right equipment at the ready!

Important hospital equipment to stash in your pockets include:

  • 10mL saline flushes
  • Alcohol wipes
  • Medical Tape
  • 4×4 gauze

Important equipment that you should be bringing to work and have on you include:

It may be a good idea to also carry with you a bottle or two of lotion or barrier cream, so you’re not always needing to run to the clean utility room.

Having all this equipment will save you time and make you more efficient and keep you organized.

Related Article: 

7. Know When You’re Actually Working

Knowing when you’re working is an important aspect of how to stay organized as a nurse.

I would be lying if I said I never got a call saying “where are you – you’re on the schedule for today”.

I use Nurse Grid to keep track of my schedule. This app is specifically for nurses. What I love is that you can see your colleague’s schedules as well and even request a shift-switch within the app itself.

It’s simple and yet functional. Whatever app or calendar you use – make sure you always know when you’re working!

Related Articles:

nurse grid

Hopefully, you found some of these tips helpful when searching how to stay organized as a nurse! Are there any other tips that have helped you? What other areas do you struggle with?

Let us know in the comments below!

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Covid Nursing Tips Featured Image

Top 6 Charting Tips for Newbie Nurses

Top 6 Charting Tips for Newbie Nurses

The joys of nursing: making a difference, decent pay, and… charting!? Adjusting to the new role as a medical professional is exciting, but unfortunately, there is SO much to learn that nursing school unfortunately just can’t teach you.

One obstacle that new nurses face is learning how to chart quickly and effectively. Learning a new computer system, especially when you’ve never even professionally charted, can be daunting.

Learning time-management and charting skills are difficult enough, let alone actually taking care of the patients! Use these Top 6 Charting Tips for Newbie Nurses to help you transition into the nursing role and help you chart like a pro!

1. Have a System

A critical factor in organization and time-management as a nurse is to have a system for whatever you do. If you go through a literal checklist, you are less likely to miss something, especially as a new nurse!

It can be difficult to chart an entire patient encounter and not miss details, and going through your personal system that you’ve created can help you minimize charting errors. Remember this charting tip throughout the rest of the tips below – developing your personal system is critical in your time-management as a nurse.

Knowing where you write things down, where you chart things, and in what order will help you stay organized in a chaotic environment.

Your system should be flexible as patients and hospitals can be unpredictable. With time, you will be able to adjust your system to be less task-oriented and more holistic.

2. Write it Down

Something that almost EVERY organized nurse does is write down their patient information in some form or another.

You are probably somewhat familiar with this as you likely wrote down every piece of information you could in clinicals. But now you’re in the big leagues – you are responsible for your patient and the information you write down is important.

Seeing multiple patients with similar scenarios, it is easy to forget specific information or mix up information between two similar patients. What you write down will be your brain.

When a physician or other medical professional asks you a question about your patient – the last thing you want is to NOT know! Even if it takes you 10 seconds to find on your paper – this is better than saying “I don’t know”, and physicians and other healthcare staff will respect that.

Many different electronic medical records (EMRs), especially within the hospital, will have printable “patient care sheets” which can provide you with information in the medical record such as the patient’s demographics, medical history, ordered medications, and recent labs.

This can be VERY helpful – but you must have a system in place. Find a specific place to write down the information that isn’t pre-populated.

Where is their IV and what gauge? What is their history of present illness, aka what brought them into the hospital? Find specific places to write this information down on the sheet, and this will help you stay organized and be able to draw accurate information quickly and efficiently for accurate patient charting.

Quickly write down your patient assessments, as well as any new information the patient presents. I also recommend writing down vital signs on your sheets as well to be able to monitor and trend them accordingly. Sometimes when just reading them on the screen, you can miss important information.

Learn your medical abbreviations. If there’s not one – make it up! As long as YOU understand what you are writing – it serves its purpose. This will save you time AND wrist-pain.

If you’d like, I have free patient care organization sheets which you can print and copy to write down patient information and stay organized. You can sign up with your email for free here.

One last note – write down your times; the time you assessed them, the time you emptied their urinal, the time you assisted them to the bathroom, you get the point.

I can’t even count how much time I wasted trying to estimate what time I performed some sort of patient care because I didn’t write it down.

3. RTC

This is probably my BIGGEST recommendation – learn to chart it in real-time.

This is one of the key skills I’ve learned which tremendously helped my first year on a telemetry floor, and subsequently my time in the emergency department.

This is easier if you have a portable computer on wheels, as many units will. By real-time, I don’t mean while the patient is talking. Focus on the patient and give them your undivided attention and assessment skills.

Chart directly AFTER your patient encounter, exit the room (or stay in), and set aside 5 minutes or so to chart everything that occurred right outside the room.

This accomplishes a few things:

  • Everything is FRESH in your mind, and your charting will be more accurate.
  • If you realize you forgot to ask or assess something and realize it while you are charting, you can just walk right into the room and ask/assess the missing information. This happens much more than you expect!

As a new nurse learning a new charting system, you may not be able to finish the entire chart within 5 minutes. If not, I recommend still setting aside about 5 minutes directly after seeing the patient to chart.

Start with your patient assessment, as this is what will be the most difficult to remember specifics later on (you’re going to be doing 5+ assessments).

If you do not get to your patient care plans, patient education, tasks, or another facility-specific charting, that is okay! You can chart this information when you have some downtime later. Just keep a checklist and know what else needs to be charted to come back to later. You will get quicker with time!

4. Nancy Drew it

Once you get to know the electronic medical record, you can really start to use it to streamline your patient care and investigation skills.

One way you can utilize the system is to find information that you didn’t write down (like you should have). One common way I “Nancy Drew’d It” was when I forgot to write down times I performed patient care.

You can go back into the system and cross-check your times. By this I mean, look to see something already charted in the system that you can relate back to when you performed the task.

Did you administer the patient’s medications 10 minutes after your assessment? Look into the EMAR and see what time the medication was administered (already charted in the system), and subtract 10 minutes. Easy enough right?

Learning the EMR and being able to navigate it quickly and efficiently will help you gather appropriate patient information. Learn to look back at old labs (I’m talking 6-12 months ago.. What exactly is their baseline creatinine?), at old medication lists, at imported data from primary care offices, pharmacy information, and at History & Physicals from previous admissions.

Your specific charting software will limit or expand your ability to do this, but all EMR software will have ways of gathering information which you will learn to navigate with time.

5. Work Smart!

As a nurse, you work hard enough! When you are able, try working smart!

If your EMR allows, duplicate a previous assessment and adjust what needs to be changed based on your assessment. Whether it is your assessment or another nurse’s, it really doesn’t matter – just make sure that the charting reflects your actual assessment.

This mainly just saves you mouse clicks – but also your valuable time.

Providers have shortcuts with charting as well. When dictating or typing their H&Ps, they often utilize “macros” or templates that list out a normal Review of Systems and Physical Exam. They change what needs to be changed and it allows them to chart relatively quickly.

Unfortunately, nurses tend to have to chart in a less convenient way, which usually involves multiple clicks, checkboxes, and forms. This is convenient for coding and billing, as well as for insurance companies for data mining purposes, but it is NOT convenient for the nurses.

When the EMR allows, it will save you a good amount of time by duplicating an assessment. Some EMRs will have offer better functionality in this aspect, and others will not allow it at all. It will also depend on the facility and its policies regarding charting duplication.

6. CYA

Nurses are the backbone of the healthcare industry. Unfortunately, the responsibility of our patient’s health ultimately can trickle down to the RN taking care of them, and this can be stressful.

A nurse can find themselves in legal trouble if a medical error occurs and he or she did not catch it (or worse – caused it).

Due to the unfortunate trend in patients suing hospitals and staff, it is vitally important to cover yourself with your charting. Chart EVERYTHING that you can.

Always document each notification you made to the Provider, and the conversations you have with the patient/family. Use direct quotes when possible, even if what was said might not be rated PG…

When in doubt, inform your charge nurse or director of anything that you don’t feel comfortable with – and CHART it! By initiating the chain of command, you did your duty as the nurse.


Hopefully, with these charting tips, you’ll be a little less stressed about charting and able to focus more on what truly matters – patient care!

Drop a comment below if you have any other charting tips that will come in handy for new and experienced nurses alike! As always, let me know of any other blog suggestions you’d like written about!

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Nurse Charting Nurse Documentation Abbreviations