What Nurses really Want to Say When They Chart

[SICUshortCait]

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 Daenerys Targaryen calmly walking through fire as everything burns behind her.

Let's be real though; the sense of humor we have gained from this job can only be kept at bay for so long. Any nurse could write a book about their life and entertain the masses enough to retire like JK Rowling and be done with it. Our notes, however, appear to be lacking that certain je ne sais quoi that makes us who we are. That is, until you know what it is we are really saying. At this point even the MDs are able to joke about the note that will follow our conversations. So keep on writing your notes, hopefully with a smile, and know that I know what you really mean by:

"MD aware. No new orders received" aka told physician and nobody cared; butt covered

"Patient arrived to unit" = Here we go again. All hands on deck

"Patient alert oriented and independent" = yessssss

"Patient Intubated and sedated" = That'll do donkey. That'll do.

"Will continue to assess and notify MD with changes" = RN knows something is up; will continue to harass physician until something is done about it

"Patient repeatedly reminded to..." = oh my god. oh my god. sttaaahhhhpppp

"RN called provider to bedside, provider at bedside to assess" aka They saw this **** too, it was not just me!

"RN asked provider for...; provider said not necessary at this time" = Oh man I told you so

"Notified charge nurse patient requiring 1:1 care" = Can someone throw me a life raft over here? Anyone? Anyone? Buelleeerrr??

"Lab notified RN specimen clotted" = are you serious..seriously..

"Medication not available" = Sorry sir our pestle and mortar downstairs must have broken today

"Respiratory Therapist at bedside" = I needed an adult. They can't even breathe around here without us today

"Patient had large bowel movement" = Code Brown! Save yourselves! How was the ceiling even in range?!

"Patient ambulated around unit" aka I am NOT about to disimpact you today sir

"Patient managed to get out of restraints and..." = ...sigh. Houdini over here. What the *... We've got a lively one over here folks!

"Patient demanding to sign out AMA" = oh please oh please I triple dog dare you (jk please just get better and be nicer)

"at 0745 RN noticed patient showing sings of distress, 0830 first unit hung..." = so this is the first time I've sat down, my day was a ****show and my shift is over. This is going to be one long run on note and that's that

"RN notified resident... resident stated we will discuss on day rounds" = Where are the adults at this party? can we get some coffee up here?

"RN walked into room, found family touching equipment" = AW HELL NO

"At 0700/1900..." = because of course that's a good time to start anything

"D/C teaching complete; patient being discharged today" = You're on your own now. You know what to do. Take your meds. Don't talk to strangers. You can do this! buhbyeee

The truth is our notes can never really tell the whole story, so if you're not one of us: buy your nurse friends a beer and ask them about their day. Steady your stomach and prepare for some anonymous stories and an all around good time. We documented. It happened. Just check our notes.

[Davey Do]

"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.

[Davey Do]

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!"

[Davey Do]

"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.

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[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.

[Have Nurse, ADN, RN]

So hailarious. I read and re-read this one today. Can't stop laughing...................!!!!!!!!!!!!

Great humor. Telling it like it is..

[Cat365]

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 :)

Patient is malodorous and covered in fecal matter. Patient taken to decontamination shower by RN and tech. Patient bathed and placed in gown. Wounds noted on buttocks and groin. See wound charting.

The floor RN thanked me.

[Cat365]

Patient is still agitated fighting against restraints. Patient is oriented to person but disoriented to place and time. Patient repeatedly yelling "Get the f*** off me. Jane get off me and leave me alone. I'm gonna kill you." Patient unable to be reoriented. Patient repositioned with the assistance of security. Restrains continued.

This guy is batpoop crazy, has no idea where he's at, I have no idea who Jane is, and he hasn't reached the I'm sleeping it off stage. No way I'm letting him out of restraints. Maybe when he passes out.

[Merrylee Carr]

Pt states he allergic to almost all pain medications including Tylenol, Ibuprofen, tordal and morphine with symptoms being "my throat swelling closed" = wants Dilaudid, enough of a frequent flyer he has learned that "makes me really sick" does not constitute a true allergy that we would be concerned enough to avoid giving

Security called and MD notified, order for Hadol received = I'm tired of paging the MD and being treated like I'm over reacting, had to call security and allow a scene to get what I needed

[scribblz, BSN, CNA, LPN]

On 8/1/2016 at 10:55 AM, dec2007 said:

I think what makes me most crazy is when a patient and their family expect us to "fix" their loved one, yet refuse or defy every medical intervention proposed to them. Yet it is still the hospital's fault (or more accurately, the nurse's fault) that said loved one has not been healed. I often would like to say "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?

THIS!! Every freaking time. Like do you go to a restaurant and then refuse all the food on the menu... and then throw a fit because you're still hungry??

[kakamegamama]

9 hours ago, Merrylee Carr said:

Pt states he allergic to almost all pain medications including Tylenol, Ibuprofen, tordal and morphine with symptoms being "my throat swelling closed" = wants Dilaudid, enough of a frequent flyer he has learned that "makes me really sick" does not constitute a true allergy that we would be concerned enough to avoid giving

Security called and MD notified, order for Hadol received = I'm tired of paging the MD and being treated like I'm over reacting, had to call security and allow a scene to get what I needed

Just a note-----it is "toradol" and "Haldol". Hadol is a region in France. Be careful with your spelling of drug names. It is important. And, if your avatar is your real name, you probably don't want to keep it or your photo (if that is really you). This is supposed to be an anonymous site.