My Clinical “Brain”

Every nurse and nursing student has his or her own method of tracking important patient information throughout the day. These are generally one- or two-page tools known as “brains” – they include spaces for recording vital signs, medication administration, details from report, current labs, etc.

I’ve found a few over this year that gave me a good place to start, but there was always something about the layout or some missing tidbit of information that made it “not quite right” for me. So inspired by a classmate who created a layout that worked for her, I decided to create my own. After a few months of cutting and pasting and rearranging, I have succeeded!

So without further ado, here is Nurse Teeny’s Clinical Brain! There is space for two patients per sheet and and it is double-sided: side 1 has a place for patient info., vitals/CBGs/I&Os, and general notes; side 2 features medications by hour and labs.

Feel free to download and adopt/adapt for your own clinical use. 🙂

*Note: This brain has since been updated to include the patient’s diagnosis and is available in both Word and PDF formats.*

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