What Nurses really Want to Say When They Chart - page 3

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   Adele_Michal7
    "Patient is aware of the risks and benefits, including but not limited to---" - Patient knows they're making a poor choice and doesn't give a flying fruit basket.

    "Patient resting comfortably and noted with deep, unlabored resps" -Patient didn't bother us all night

    "Patient exhibiting signs and symptoms consistent with labile mood; not amenable to staff redirection attempts" -Patient is acting bat crap crazy and there's nothing we can do about it... For now.
  2. by   Adele_Michal7
    "High lab value received; paged on call hospitalist and awaiting return call. Endorsed to oncoming nurse." -I tried my best so don't blame me if the next shift drops the ball!
  3. by   ixchel
    This reminds me of a conversation I had with a surgeon when I asked for parameters that might warrant calling him over night. He said, "don't contact me. Contact Doctor Aware."

    Anytime you EVER see the words "no new orders received" in my charting, it means one of two things:

    1. The patient is being unbelievably impossible regarding something either dangerous or not at all medically indicated, and thankfully the MD agrees

    2. The hospitalist is being an asshat

    "No orders received" is my polite way of saying, "are you effing kidding me," and other variations of, "what the eff, man."

    As for the rest of my list, AN will asterisk out enough words that it would make no sense.
  4. by   Scrubs_n_sirens
    "Patient calling out of room, repeatedly, for nurse. Upon looking in on patient, found patient in no distress, lying quietly in bed. Upon physically walking into room and engaging patient, patient began to writhe in bed, screaming, and demanding 'something better than toradol!'" Patient is a drama llama, also should get 4 cc's of NorSal, fast push or titrated to nurse comfort.
  5. by   brillohead
    Quote from ixchel
    This reminds me of a conversation I had with a surgeon when I asked for parameters that might warrant calling him over night. He said, "don't contact me. Contact Doctor Aware."

    Anytime you EVER see the words "no new orders received" in my charting, it means one of two things:

    1. The patient is being unbelievably impossible regarding something either dangerous or not at all medically indicated, and thankfully the MD agrees

    2. The hospitalist is being an asshat

    "No orders received" is my polite way of saying, "are you effing kidding me," and other variations of, "what the eff, man."

    As for the rest of my list, AN will asterisk out enough words that it would make no sense.
    I can neither confirm nor deny that my charting recently said, "Attending informed of sepsis criteria; stated not concerned because patient not hypoxic".

    Fever of 103 untouched by regular doses of Tylenol, chills, sweats, aches, shallow/rapid breathing, significant drop in BP (I wanna say it was around 105/50), O2 sat = 90%...

    I can also neither confirm nor deny that within five minutes of my charting about his lack of interest, the attending came and personally checked on the patient.

  6. by   hecallsmeDuchess
    Quote from billswife
    That's so cool!!!! You have a "do not admit" list??? I want one!!!!
    I didn't know we had one at my hospital either until our pt (frequent flier and all) went ballistic and threatened to deal with a doc and make sure he was dead, he earned himself a " do not admit" to our hospital. He could go to the other branches of our hospital but not our particular one. Most nurses heaved a sigh of relief and exchanged some not so subtle high fives when we heard that.
  7. by   ixchel
    Quote from brillohead
    I can neither confirm nor deny that my charting recently said, "Attending informed of sepsis criteria; stated not concerned because patient not hypoxic".

    Fever of 103 untouched by regular doses of Tylenol, chills, sweats, aches, shallow/rapid breathing, significant drop in BP (I wanna say it was around 105/50), O2 sat = 90%...

    I can also neither confirm nor deny that within five minutes of my charting about his lack of interest, the attending came and personally checked on the patient.

    That would get a big ol' NO ORDERS RECEIVED from me!
  8. by   Vee-otee
    you made my evening. heeheheheee
  9. by   NurseOnAMotorcycle
    A FLACC scale on a verbal pt...

    seeking!
  10. by   prunejuice&BPs
    "Patient displaying agitation, running around the unit, using expletives turning on all the faucets and flushing all the commodes. Patient tackled another patient and brought him down to the floor. Physician notified, order placed for oral Haldol and Ativan. Medication administered. Continue to monitor patient. 1:1 observation ordered. "

    Translation: Patient out of control, dangerous to self and others. Physician afraid to use all means to control because he is afraid of the patient and doesn't want to violate his rights
  11. by   BeenThere2012
    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
    Social Services evaluation requested! (Dump...not fair really. Kind of joking...hee hee)
  12. by   EllaBella1
    Hahaha. I guarantee that I chart a "no new orders received" at least once a shift. I also like to chart quotes from patients and/or family members when they are being completely inappropriate or disagree with the physicians orders/plan of care.
  13. by   BeenThere2012
    Parents refuse to have name and placed on child after multiple attempts to explain safety comcerns. Charge nurse aware, MD aware. Risk management aware.

    Read: Wont be my license on the line.

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