What Nurses really Want to Say When They Chart - page 2

We all know we have to keep it objective and professional when we write a note, but clinical notes are really masterpieces of restraint. They summarize our chaos in a way that makes us look like... Read More

  1. by   Browneyes80
    Ha! I like [emoji23][emoji23][emoji23][emoji23]
  2. by   mercurysmom
    "1700: Pt A&Ox4, steady on feet, independently amb in hallway q15min, denies discomfort or anxiety, states "I'm waiting for my boyfriend, the ********** said he was on his way."
    2010: pt not in room. unit searched, security notified. Pt discovered in ambulance bay, escorted back to floor. Pt drowsy, pinpoint pupils, Pulse 55 reg, Resp 12/min. Clave missing from saline lock, tubing tied in a knot. MD notified, new order rec'd for narcan if resps<8 or LOC, remove PIV. Pt remains on 1:1 supervision. "

    I hope I'm the off-going shift!
  3. by   brillohead
    Quote from Ruby Vee
    Dr. Imaflamingdonkeybutt paged; no orders received.
  4. by   qestout
    How do you nicely chart "patient is filthy and stinks to high heaven", "is quiet until they see me, and then become talented, moaning, pain med seeking actors", and "the family needs to leave, they are causing problems"? I manage it, but would like to hear others thoughts
  5. by   Sun0408
    Love the OP!!! Cracks me up [emoji23][emoji23][emoji23]
  6. by   Mandychelle79
    Quote from qestout
    How do you nicely chart "patient is filthy and stinks to high heaven", "is quiet until they see me, and then become talented, moaning, pain med seeking actors", and "the family needs to leave, they are causing problems"? I manage it, but would like to hear others thoughts
    Pt is exhibiting poor adls and is malodorous. Encouraged patient to shower and offered clean clothing.

    Pt rAtes pain 15/10 but has been observed resting quietly in bed, playing on cell phone, engaged with peers.
  7. by   kalycat
    "Frequent requests this noc; patient particular with cares." They rode my last nerve like a stolen bike. Rad.

    "Patient has difficulty observing socially appropriate boundaries with female staff." He requested a straight cath and testicular massage while I was updating the white board. [emoji15]
  8. by   calivianya
    Quote from kalycat
    "Frequent requests this noc; patient particular with cares." They rode my last nerve like a stolen bike. Rad.

    "Patient has difficulty observing socially appropriate boundaries with female staff." He requested a straight cath and testicular massage while I was updating the white board. [emoji15]
    Reminds me - the other day one of my coworkers was asked by a female patient to eat her out. If that wasn't bad enough, one of the patient's home meds was valacyclovir PRN. Would have loved to know the exact PRN indication - was that for sores on the lips or on the genitals?

    "Patient requesting sexual acts to be performed. Patient informed staff were present to treat medical issues only."
  9. by   Lev <3
    "Patient states that pain is "better" after dilaudid administration but continues to rate pain at 10/10. Comfort measures offered, which patient declined. "
  10. by   Adele_Michal7
    Quote from calivianya
    Reminds me - the other day one of my coworkers was asked by a female patient to eat her out. If that wasn't bad enough, one of the patient's home meds was valacyclovir PRN. Would have loved to know the exact PRN indication - was that for sores on the lips or on the genitals?

    "Patient requesting sexual acts to be performed. Patient informed staff were present to treat medical issues only."
    Oh. My. Gawwwwwwwwwdddddddd.
  11. by   1fuzzyRN
    "Patient is a poor historian." = Patient is prescribed an ACE inhibitor, insulin and an inhaler but denies any medical history.
  12. by   A&Ox6
    "Patient seen ambulating through the unit. Requests medications to be brought to bedside because of inability to walk. Client is reeducate do regarding medication times, treatment goals and unit rules."
    This is a malingerer. I will not play those games. She can definitely walk to the station. If she says she fell, I will not take the responsibility.
  13. by   blondy2061h
    "Report given to oncoming RN" Peace out, until next time folks

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