There is no "One Way" to go about your day. There are several techniques out there, like using a timer, using sticky notes or a notebook, charting as you go along vs. charting at the end. I'm going to talk about what has worked best for me.
First, before the day starts, I make sure all my rooms are set up and stocked with the right equipment and supplies (alcohol swabs, leads, gloves, gowns, blankets, etc), but particularly oxygen masks/nasal cannulas. I now also bring in a couple of urine sample cups, which is actually not in the room usually, but I've personally gotten behind in my day only due to collecting urine specimens. This way I remember to get a sample the second my patient walks in. So if there's something you know that your patients usually need on your floor that's not usually not stored in the room, bringing it at the start of the shift is a great way to help you remember as the day progresses. I also like attaching 3 leads onto the monitor already, which makes one less thing to fetch when I have a new patient. Finally, I wipe down most everything I'm going to be touching (computer keyboard, mouse, monitor buttons, light switch, door handles, etc).
When a new patient comes, I say hello, introduce myself, and ask them their name. Honestly, I get annoyed when the EMT bringing them in answer for them, since (as all nurses know) I'm not asking the patient their name just to be nice, I'm actually assessing their cognitive level. While getting report from the EMT or triage, I start grabbing (1) gown, (2) belonging's bag, (3) urine cup, (4) blanket and (5) leads if there aren't any on the monitor. I instruct the patient to put the gown on then go fetch the rest of the things needed for them while they are changing. These things are: (1) blood pressure cuff, (2) pulse ox, and (3) IV start kit. In my ER, these can't be kept in the room because we charge the patients individually for them as we take them out. If it were up to me, there should just be a whole New Patient Kit with these eight items that every new patient gets when they come in. Anyway, I attach the patient to the monitor and get a baseline reading for their vitals while they tell me what is going on. Then after my primary assessment, I immediately ask for a urine sample (since most likely the doctor will order a urinalysis).
While ideal, I obviously have to keep this system flexible. Do I need to help the patient remove their clothing? Can the patient ambulate to the bathroom? Is the patient in acute distress? Do I have other patients that need more immediate attention?
Similarly, if I had all the time, I would prefer to chart as I go, but when we get slammed with tasks and new patients, obviously the priority is to complete the tasks and patient care instead of sitting at the computer documenting. In which case I made myself a backup plan. I take a sheet of bond paper, fold it into six sections (twelve sections total back and front), and label each section by the hour from the start of my shift: 0700, 0800, 0900, and so forth. That way I can quickly jot down if something happens when it happens, then document it on the computer later. I even make check boxes for tasks I need to complete at a certain time, such as medications, then check them off when I'm done.
This is not the system I started with at all, and I'm sure I will continue to modify it as I pick up new techniques. It will also definitely change depending on the needs of the floor you're working on or the system in place at the hospital. However, I believe finding a system that worked for me is definitely one of the top things I had to work on as a new grad.
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