What Nurses really Want to Say When They Chart - page 5

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   FutureDNP2021
    Quote from Lev <3
    "Offers no complaints" - patient doesn't want to bother me and I am too busy to ask them what they want.
    Im going to use this one, Thx =)
  2. by   FutureDNP2021
    Quote from kalycat
    "Frequent requests this noc; patient particular with cares." [emoji15]
    Good one
  3. by   WKShadowRN
    What I wanted to say: pt is an idiot to keep returning for the same problem and refuses to follow up appropriately. He is wasting our time and resources.

    What I said: pt returns for cocaine related chest pain for the 3rd time in as many months. No EKG changes, no elevated enzymes, no subjective findings to attribute presentation.
  4. by   Garden,RN
    I went into nursing later on after having worked in the business world. Most of the time what I wanted to say. " Why is so much of health care set up in such an inefficient way?" " "Why are we documenting so many senseless, mindless, unnecessary things that rob time away from actual patient care?"
  5. by   billswife
    Quote from Garden,RN
    I went into nursing later on after having worked in the business world. Most of the time what I wanted to say. " Why is so much of health care set up in such an inefficient way?" " "Why are we documenting so many senseless, mindless, unnecessary things that rob time away from actual patient care?"
    Yep, that pretty much sums it up.
  6. by   Nightshade1972
    Quote from 1fuzzyRN
    "Patient is a poor historian." = Patient is prescribed an ACE inhibitor, insulin and an inhaler but denies any medical history.
    I'm reminded of some of the claimants my husband's dealt with over the years (he helps ppl file for disability). Hubby looks through their history, and asks them about their high blood pressure and their diabetes. They insist they "don't have" HBP/diabetes. My husband says, "Really? Then why are you on (HBP meds) and (diabetes meds)?" The claimant smiles brightly and says, "Oh! I *used* to have HBP/diabetes, but since I started on those meds, I don't have them anymore!"

    *Facepalm*
  7. by   Nightshade1972
    Quote from WKShadowRN
    What I wanted to say: pt is an idiot to keep returning for the same problem and refuses to follow up appropriately. He is wasting our time and resources.

    What I said: pt returns for cocaine related chest pain for the 3rd time in as many months. No EKG changes, no elevated enzymes, no subjective findings to attribute presentation.
    My husband once had a claimant who had something like 27 cocaine-related heart admissions in 24 weeks. He still couldn't get a clue.
  8. by   Davey Do
    Quote from Garden,RN
    "Why are we documenting so many senseless, mindless, unnecessary things that rob time away from actual patient care?"
    One reason is because the accreditation and benefitting agencies need to stay afloat and have a reason for existence.

    "Your assessments don't have an area that identifies the patient as a high risk for hangnails or papercuts" they say.

    Bam! Administrators respond with a knee jerk reflex and nursing assessments then have drop down indicators for identifying high risk hangnail and possible papercut patients!
  9. by   Davey Do
    Quote from billswife
    "So, then exactly WHY did you come to this facility for help if you will not allow us to do perform any of the things we know will help your loved one." Really, why DO people come to the hospital if they don't want any help we have to offer?
    There was a high maintenance recidivistic psych patient who gets admitted through ER after smoking crack and claims to be suicidal. During one stay, he became upset with me when I "provided reality orientation".

    He angrily informed me,"I'm not coming back here!"

    "And tell your friends!" I replied.
  10. by   Davey Do
    Quote from WKShadowRN
    One of my favorite notes I wrote within the past year was about a woman with pseudoseizures who conveniently went unresponsive as I tried to get her from the wheelchair to the stretcher. I gently whispered in her ear to get up that I knew she was not seizing at the moment.

    She abruptly opened her eyes widely and yelled at me for telling her to quit faking.
    You cured her, WKShadow! And without an invasive intervention!

    I once cured a patient with pseudoseizures by a technique known as "laying on of hands". Some call it "sternal rub".

    The patient immediately regained consciousness and exclaimed, "That hurt! I was having a seizure!"
  11. by   Davey Do
    Quote from 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.
    fruit-basket2-jpg
  12. by   Purple_roses
    Asked patient what measures we can try besides dilaudid, morphine, Norco, or fentanyl as none of these can be given for another two hours. Patient refused all other measures and continued pushing call light for narcotics every 5 minutes.

close