Staying Organized: The Brain

The folded sheet of paper that keeps several patients straight, its sections, and a worked example for a chest pain patient.

Below is how I stay organized with each patient. I typically grab a white blank sheet of paper, fold it in half, and note the sections below. It is important to stay organized because you will have multiple patients at a time and you need to know what each patient is there for, what's pending, their allergies and so forth.

The Sections

Down the left side of the folded sheet: • Chief Complaint • History • Assessment • Pending, with a checkbox for each item • A CBC fishbone (WBC, HGB, HCT, PLT) and a chemistry fishbone (NA, CL, BUN, K, CO2, CRT, GLU) Down the right side: • Allergies • Full Code? • Diagnoses • The patient label

A Worked Example

This is a simple example of how it would look for a chest pain patient. • Chief complaint: CP, SOB x 2 hours. • History: DM, HTN, PE, IVC filter (metformin, Norvasc, Coumadin). • Assessment: 7/10, midsternal, nonradiating, worsens with inhalation. HR 117, diaphoretic, anxious. • Pending: CTA chest, chest X-ray. • CBC: WBC 9.2, HGB 11.3, HCT 32, PLT 321. • Chemistry: NA 137, CL 101, BUN 16, K 4.2, CO2 22, CRT 1.2, GLU 155. • Also sent: D-dimer 506, INR 2.1. • Allergies: none. Code status: full code. • Patient label: Mary Doe Jones, 03/16/1977.

Staying Organized: The Brain