What Nurses really Want to Say When They Chart
A peek into what we are really thinking when we jot down that clinical note...
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" a.k.a 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..." a.k.a 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 voiding <30mls/hr"- RN has voided 0mls/12hours....
"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 F... 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 shitshow 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.Jun 6, '16In the peds world:
"Patient found unattended and jumping on bed. Parents unable to be reached. Cage crib ordered." = A@@ covered
"Parents returned from 'smoke break' stumbling, incoherent and with smell of alcohol/ weed on their person" = CPS on speed dialJun 6, '16Pt educated about unit rules.... Other patients are complaining but pt not yet to the point where anything can be done.
Pt had frequently been requesting PRN medications---'med seeking
While talking to patient pt became irrational and later was found on floor in bedroom, bed alarm turned off.... Great, borderline personality disorder anticsJun 6, '16"Medication given per order." ---- Though they would have liked it a lot more often.
"Patient missing from room for 2 hrs. Patient stated he went to get...." -- I was aware he was gone and Lord knows what he did while out of the room"Jun 7, '16"Patient educated on the importance of post-operative ambulation/incentive spirometry/adhering to diet/staying on the unit. Patient refused." ---- you can lead a horse to water but you can't make them give a damn about their own medical treatment.Jun 8, '16"Patient attempting to converse with an Alaris pump, states 'That uppity bastard won't even TALK to me.'" (Patient is bat-guano crazy and he's gonna do something, I just know it!)
"Patient complaining that three lovely young nurses and one fat, old ugly nurse are attempting to rape him." (I told you he was gonna do something really crazy. He ripped out his Foley -- again -- and hasn't been able to pee. We had just given him his IV Lasix and the bladder scanner says he's got 1200cc in there. If we don't get him cathed, he's going to BURST.)
"Patient reports that his last alcoholic beverage was just before midnight the night before his surgery when he drank his usual fifth of Jack Daniels and case of Budweiser. Temperature and heart rate are elevated, patient is becoming increasingly restless and agitated. Extubated to 60% face mask, but oxygen saturation are trending downward to the mid-80s and patient complains that he "can't breathe." Dr. Imaflamingdonkeybutt paged; no orders received." (Patient getting ready to go full blown DTs on us, respiratory status isn't all that stable and whose freaking idea was it to take out that ET tube anyway? It's going to have to go right back in, but at least we'll be able to sedate his ass.)Jun 8, '16Pt strongly encouraged to (insert whatever reasonable request here) in order to improve (whatever is going down the tubes.) States not interested (actually stated "H**L no!")
Pt discovered with O2 sat in 70's when leaving bathroom without assistance, strong odor of tobacco smoke noted.
Pt reinstructed on importance of following diet restrictions (due to DM II, pancreatitis, whatever.) Continues to have family bring in (insert fast food of choice here.)
I could go on for days......Jun 8, '16Man, this is one thing I love about Hospice. There are no compliance/noncompliance issues.
Hospice is all about choices. We don't give them orders to follow, we give them recommendations based on their symptoms and what they have identified as important.
People have the right to make bad decisions. "Discussed liberalized diet with patient, recommended still watching the amount of Sodium consumed. Instructed to call Hospice if any increased swelling or difficulty breathing."
Patient eats an entire bag of potato chips because it's been years since any passed his lips. Blows up like a balloon. "Seen for report of dyspnea and edema. Bibasilar crackles, moist cough, 2+ pitting edema feet to knees. Ativan 1mg SL given. Roxanol 5mg SL given, after 30 minutes no relief, additional 5mg given. Med neb administered. MD notified, order received for extra dose of Lasix today and tomorrow, and re-evaluate. Patient states feels better now. Patient and family reviewed POC, agreed with extra Lasix, comfortable with administering Roxanol and Ativan, will call if any questions or change in condition. Patient resting comfortably in bed, states does not want O2 at this time."
Usually, the patient will still indulge, sometimes needing symptom relief, sometimes not. When it works right, they call, get instructions, say they've got things under control and only need a follow up call later, no visit until the next day for follow up.Jun 8, '16"Patient attempted to strike nurse when informed unit pantry was out of chocolate pudding."
Patient is a violent POS who should probably be in prison (and probably has been). Add him to the "do not admit" list in a hurry.Jun 10, '16"Family tearful; emotional support and education provided." AKA, I pulled 20 minutes out of my butt to listen to pt's well meaning family member expound upon how all the narcotics they didn't let me give their actively dying loved one are making them agitated and combative.
"Pt/family not receptive to education at this time, declining available interventions." AKA, I worked really hard to be nice and explain very carefully what I can do about the situation at hand, and got yelled and kicked out of the room as thanks. Butthead.
"Pt rested comfortably overnight with eyes closed, PAINAD 0, with all safety measures in place." AKA, YAAASSSSSS, pt didn't fall, didn't have pain, and DIDN'T BOTHER ME.Jun 10, '16"Offers no complaints" - patient doesn't want to bother me and I am too busy to ask them what they want.Jun 10, '16"Patient given PO, ok per MD." - verbally given go ahead to give patient food without electronic order (in ER) so if a floor doc gets mad at me - I got permission.Jun 10, '16Quote from Pangea ReunitedThat's so cool!!!! You have a "do not admit" list??? I want one!!!!"Patient attempted to strike nurse when informed unit pantry was out of chocolate pudding."
Patient is a violent POS who should probably be in prison (and probably has been). Add him to the "do not admit" list in a hurry.
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