Chart Audits -- I Couldn't Make This Up!

Nurses General Nursing

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

In the wake of a rather silly lawsuit (patient claimed that three young, beautiful women and one fat old broad -- that would be me -- "strapped him down and fondled his privates" all night long and while he had rather enjoyed the experience, upon reflection he felt that "it just wasn't right, and other people wouldn't be as opened minded.") our manager called a staff meeting to ensure that such a thing would not happen again. (The lawsuit -- I'm sure she doesn't actually believe we sexually assaulted the patient). One thing that came out of the meeting was that there are patients who are as crazy as bedbugs but the charting doesn't reflect that. "Let's make sure we document if the patient is confused, people."

That mandate has led to some rather interesting charting:

"Patient grabbed my nuts and yelled "you won't get away from me this time." (Nurse wasn't a native English speaker. CNA pointed out that "nuts" isn't proper terminology. Nurse revised the charting to read that the patient "grabbed my balls.")

"Heard patient screaming and rushed to room to find Foley catheter wrapped around his hand and stretched to near breaking. Patient complains of penile pain. Teaching done re: correlation between pulling on Foley catheter and penile discomfort." Later, the nurse charted that she "entered the room to find Foley catheter lying on bed next to patient. Patient states that "some dude came by and pulled it out. Honest!""

"Patient restless and agitated, asking for water despite NPO status. Claims that "that guy" (pointing to intubated, comatose patient in the next bed) gave him some earlier and he can't understand why he won't just go get him some more."

"Patient concerned about hearing voices. Intercom silenced." And later on that shift, "Patient found with arterial line in teeth, bleeding from radial artery. Pressure held. Patient claims that the voices told him to take that thing out or he wouldn't get to go to his room."

"Oriented to person, place and situation although he is inappropriate at times. Attempting to converse with Alaris pump." What didn't get charted was the part where he was furious that "that uppity bastard won't answer me."

"Patient is confused no matter what the doctor says. The doctor wasn't in the room wrestling with him all damned night!"

"Heart rate in the 120s, temperature is rising and patient is becoming increasingly agitated and demanding a margarita. Patient was admitted to CCU approximately 72 hours ago. Patient's wife states that patient never uses alcohol of any kind, although he does take little blue pills like candy. Wife produced 5 quart bucket filled with Valium tablets."

I guess we have a little more work to do on our charting!

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Specializes in Hospital Education Coordinator.

we have to train ourselves to document what we see not what we feel or many charts would have the statement :"patient is an idiot".

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Specializes in ICU, telemetry, LTAC.

FIVE QUARTS of valium?? Jesus in a basket. I first read "viagra" then thought, nope he would have exploded by then, not wound up in CCU screaming for a drink. What did he do, rob the factory?

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
five quarts of valium?? jesus in a basket. i first read "viagra" then thought, nope he would have exploded by then, not wound up in ccu screaming for a drink. what did he do, rob the factory?

apparently there's a doctor in montana who prescribes it by the bucket. my uncle visits him, too.

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Specializes in psych, addictions, hospice, education.

The DEA or an insurance company doesn't land hard on that doctor in Montana? Wow!

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Specializes in Oncology.

Oh gosh, I've had patients do some of the same things! Patient pulled out her foley, "Well, it was only being held by a rubber band, of course it came out!"

Another patient was upset the IV pump wasn't getting him a martini, but that he liked "that beautiful red head over there." It was a sign on the wall.

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Specializes in Geriatrics, Pain, End of Life Care.

As a night nurse, I get the privilege of documenting on all the sundowning psych patients. It really upsets the family to know that dad or mom do the things they do when the sun goes down. I try to keep the terminology as professional as possible and stay away from opinions. And remember the old adage from nursing school...if it isnt documented....it didnt happen (or it wasnt done).

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in the wake of a rather silly lawsuit (patient claimed that three young, beautiful women and one fat old broad -- that would be me -- "strapped him down and fondled his privates" all night long and while he had rather enjoyed the experience, upon reflection he felt that "it just wasn't right, and other people wouldn't be as opened minded.") our manager called a staff meeting to ensure that such a thing would not happen again. (the lawsuit -- i'm sure she doesn't actually believe we sexually assaulted the patient). one thing that came out of the meeting was that there are patients who are as crazy as bedbugs but the charting doesn't reflect that. "let's make sure we document if the patient is confused, people."

that mandate has led to some rather interesting charting:

"patient grabbed my nuts and yelled "you won't get away from me this time." (nurse wasn't a native english speaker. cna pointed out that "nuts" isn't proper terminology. nurse revised the charting to read that the patient "grabbed my balls.")

"heard patient screaming and rushed to room to find foley catheter wrapped around his hand and stretched to near breaking. patient complains of penile pain. teaching done re: correlation between pulling on foley catheter and penile discomfort." later, the nurse charted that she "entered the room to find foley catheter lying on bed next to patient. patient states that "some dude came by and pulled it out. honest!""

"patient restless and agitated, asking for water despite npo status. claims that "that guy" (pointing to intubated, comatose patient in the next bed) gave him some earlier and he can't understand why he won't just go get him some more."

"patient concerned about hearing voices. intercom silenced." and later on that shift, "patient found with arterial line in teeth, bleeding from radial artery. pressure held. patient claims that the voices told him to take that thing out or he wouldn't get to go to his room."

"oriented to person, place and situation although he is inappropriate at times. attempting to converse with alaris pump." what didn't get charted was the part where he was furious that "that uppity bastard won't answer me."

"patient is confused no matter what the doctor says. the doctor wasn't in the room wrestling with him all damned night!"

"heart rate in the 120s, temperature is rising and patient is becoming increasingly agitated and demanding a margarita. patient was admitted to ccu approximately 72 hours ago. patient's wife states that patient never uses alcohol of any kind, although he does take little blue pills like candy. wife produced 5 quart bucket filled with valium tablets."

i guess we have a little more work to do on our charting!

lol, i'm definitely guilty of charting as above at some point. it's not easy trying to objectively describe some patient antics. honestly, i think its better its write it (even if it sounds silly) than not if you can't think of a better way of describing something. usually i try to stick with the generic "a+o" , "confused/agitated" etc--but really that doesn't tell you much. i feel less like an idiot writing it though. it's interesting when everyone starts documenting mental status though--i had a patient once who was documented to believe he was in a different, glorious place every day. the candy shop. wall street journal headquarters. a trailer. the library. the circus. "pt believes it is 1988 and he is at wall street journal headquarters" thank you for telling us that, case management. "pt believes he is on the boarwalk headed to the cotton candy stand" appreciate the info, chaplain.

it's funny--but it actually helped us establish a reasonable picture of exactly how confused the patient was during the week, and we even saw when he was kind of getting better. near the end of his stay when he was kind of coming around, i asked him for for the millionth time "you know where you are?" he looked me dead in the eye "yeah, i don't f*&^ing know the answers to your questions". i moved on.

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Specializes in Rehab, Infection, LTC.

haha ruby! thanks for the morning laugh!

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FIVE QUARTS of valium?? Jesus in a basket. I first read "viagra" then thought, nope he would have exploded by then, not wound up in CCU screaming for a drink. What did he do, rob the factory?

Probably the patient's wife meant that the patient never uses alcohol... anymore! Suuuuure he doesn't! How much does SHE not use anymore?

(I've seen it and seen it :rolleyes: )

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Specializes in Psych ICU, addictions.

Sounds like some of the documentation I have to do in psych...being objective and straightforward isn't the hard part; most of my fun is in taking down patient quotations, especially during the hallucinations.

Pennyaline: agreed--one thing I learned in detox is that unless they are actively on Antabuse, many patients understate their alcohol consumption. Like the one patient who came in telling me she "only" drinks a bottle of wine a day and yet blew a BAC of nearly 0.4. I was more impressed she was actually talking coherently than anything else.

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Specializes in Peds Homecare.

All I can say is...........LOL LOL LOL:rotfl::rotfl::rotfl:. Than you for sharing, sometimes truth is stranger than fiction.

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