Nurses General Nursing
Published Dec 19, 2001
26 members have participated
CEN35
1,091 Posts
ok this is the deal..........something happened at work that caused a huge problem with the transfer of a patient. i'll explain later....after i view the poll.
well there is not enough room to explain it, in the poll question. a patient comes in, and you are asking them about their medical history. you ask if they have any of the following: chf, mi, copd, seizures, etc. all you have is a check box by each condition, and youn check it if they do have the condition. if the patient is unsure, or unclear on whether they have the condition; do you check the box or not?
thanks
me :)
wildtime88
275 Posts
I would first try to explain what the condition was a little more if they actually said they did not know. I would check their med list for any clues, but a lot of the common siezure meds are also used for other conditions. After explaining a little more in depth what the condition was i.e. passing out, uncontrolled shaking, loss of time and reviewed the meds, then I would check "no" or write next to it, if the patient was still unclear "I don't know".
This of course is taking for granted that the patient is A & O x 3 with no ETOH on board and no chance of recent head injury. In these cases it is a different story all together.
canoehead, BSN, RN
6,890 Posts
I would quote what they said or write "patient unclear"
well they said, "yes but no". then with further explanation, again said "i think so". there just was no way of clarifcation......and if it helps make your decision or answer to this easier.....he was not on anything remotely close for the tx of seizures.
kaycee
518 Posts
Rick,
I check the box and then put a question mark after it, or write pt.unsure. We don't have much room but there is a little room for a couple of words after each check box.
Hey what happened anyway?
nurs4kids
753 Posts
I would have checked it and written patient unsure, too. BUT, if the patient said, "I think so", that is enough info to either check yes or investigate further. On floor admission history, I'd let a doc know what the patient told me and document what the patient told me and that I passed the info on to the doc. But then again, you're talking about triaging, eh?
the person checked the seizure box. the pt was a paronoid-schizoo............(i.e. nutcase).......without a hx of seizures. the problem was, the attending physician at the psych facility, would not accept the patient. he idd this beacause of the alleged sz hx, and it delayed transfer about 2 hours. thehe issue needed to be clarified, and felt the pt was an unreliable source.
LilgirlRN, ADN, RN
769 Posts
I use the quotation marks a whole bunch and questions marks too. All of our old charts are now on computer so the doc can pull them up by medical recoerd number for further clarification. Half the time what the patient and/or family thinks is seizure activity isn't anyway.
cmggriff
219 Posts
Hard to say what I would do. In the interest of CYA I think it is a good idea to check the box any time the patient is unclear in answering. Some of our older patients w/o a psych hx can be pretty obtuse in their answers. Next time just shoot 'em. And shoot the doc too. Gary
debbyed
566 Posts
Don't feel alone. I swear that psyc. facilities will use amny excuse possible to delay the patient. I deal with this constantly expecially with state and criminal facilities. Patients blood sugar is 121, not a known diabetic but just ate 4 candy bars...won't take patient until BS is normal. WBC's in urine...won't take patient because they are not medically cleared......I expecially like the alcoholics with liver functions off the wall, they want us to fix them Yea, right---I'll way my magic wand----
Sorry, pet peave----I'm always very, very careful what I write on a psyc. patients chart for that very reason.
CATHYW
564 Posts
I answered that I would mark the "yes" box. Reason: if they are unable to give a definitive "no," then one would have to consider the possibility that they have +PMH of sz. To be entirely accurate, I would put a question mark in the "Yes" box, and under "comments" clarify that the pt. and/or family is unclear of pmh of seizures. That would put it in the ERP's lap to sort out.
RN-rural
5 Posts
originally posted by cen35 well they said, "yes but no". then with further explanation, again said "i think so". there just was no way of clarifcation......and if it helps make your decision or answer to this easier.....he was not on anything remotely close for the tx of seizures. me :)