The system I used to organize important information about my patients before and during a shift was not exactly high tech.

My charting system consisted of a clipboard and a sheet of plain blank paper that I would methodically divide into squares with a ruler before my shift. Each patient got a square wherein I would write clinical data such as diagnosis, vital signs, medication times, procedures, IV information and other “need to know” facts to keep my patients straight.

I would continuously update the squares with the most pertinent information throughout my shift. It was like “Hollywood Squares” meets “ER,” and yet it was effective for providing organized, quality patient care. It also kept all my patient information right at my fingertips for a smooth, streamlined shift report to the nurse taking over my patients.

Thank goodness someone has had the good sense to update my little arts and crafts project shift organization system. Actually two “someones” – a pair of RN, BSN sisters from Florida have accomplished this.  The Elson (not Olsen) sisters have invented a product called “RNReport card” to standardize patient note taking and shift reporting. This will especially benefit nursing students and nursing new grads, finding their way through the often daunting process of thorough and accurate patient documentation.

The product is a 5×7 booklet that fits easily in uniform pockets and standardizes how patient information is recorded and then communicated at shift change. It is also useful for having the most critical patient data available in the same standardized format at a moment’s notice to share with physicians or other members of the patient care team.

Standardized tools for reporting patient information also reduce the likelihood of a medical malpractice action due to inaccurate or missing patient documentation. After all, even as I was dividing my sheet of paper into squares at the beginning of each shift, the adage – “If you didn’t write it, you didn’t do it” – was always on my mind.