Chart Audits -- I Couldn't Make This Up!

[Ruby Vee]

In the wake of a rather silly lawsuit (patient claimed that three young, beautiful women and one fat old broad -- that would be me -- "strapped him down and fondled his privates" all night long and while he had rather enjoyed the experience, upon reflection he felt that "it just wasn't right, and other people wouldn't be as opened minded.") our manager called a staff meeting to ensure that such a thing would not happen again. (The lawsuit -- I'm sure she doesn't actually believe we sexually assaulted the patient). One thing that came out of the meeting was that there are patients who are as crazy as bedbugs but the charting doesn't reflect that. "Let's make sure we document if the patient is confused, people."

That mandate has led to some rather interesting charting:

"Patient grabbed my nuts and yelled "you won't get away from me this time." (Nurse wasn't a native English speaker. CNA pointed out that "nuts" isn't proper terminology. Nurse revised the charting to read that the patient "grabbed my balls.")

"Heard patient screaming and rushed to room to find Foley catheter wrapped around his hand and stretched to near breaking. Patient complains of penile pain. Teaching done re: correlation between pulling on Foley catheter and penile discomfort." Later, the nurse charted that she "entered the room to find Foley catheter lying on bed next to patient. Patient states that "some dude came by and pulled it out. Honest!""

"Patient restless and agitated, asking for water despite NPO status. Claims that "that guy" (pointing to intubated, comatose patient in the next bed) gave him some earlier and he can't understand why he won't just go get him some more."

"Patient concerned about hearing voices. Intercom silenced." And later on that shift, "Patient found with arterial line in teeth, bleeding from radial artery. Pressure held. Patient claims that the voices told him to take that thing out or he wouldn't get to go to his room."

"Oriented to person, place and situation although he is inappropriate at times. Attempting to converse with Alaris pump." What didn't get charted was the part where he was furious that "that uppity bastard won't answer me."

"Patient is confused no matter what the doctor says. The doctor wasn't in the room wrestling with him all damned night!"

"Heart rate in the 120s, temperature is rising and patient is becoming increasingly agitated and demanding a margarita. Patient was admitted to CCU approximately 72 hours ago. Patient's wife states that patient never uses alcohol of any kind, although he does take little blue pills like candy. Wife produced 5 quart bucket filled with Valium tablets."

I guess we have a little more work to do on our charting!

[erwigg]

once had a 88yo resident tell me all about therather large siders in all of the corners of the room at the ceiling-measuring about 3 feet across- he was wanting to get the baseball team out of the area so they wont be attacked. the only way to get him to be quiet was to act like Iwas getting the team out of them room.

about 10 mintues later he was concerned about getting attacked himself so he was yealling and screaming to scare them off. the cna gave the guy the idea if he was realy really quiet then they would not know where he was at.

He was asleep 5 minutes later. woke up once during the night asking for something to drink. sometime after that he passed on-I guess the spiders did get to him

[nursemike, ASN, RN]

Our order sets automatically include paging for mental status changes (which I would most likely do, even for an off-service patient) but since it doesn't specify what kind of changes, I've often been tempted to page at 0300 for mental status imporvements. Or, I would be, if it happened. Actually, I did page a neurosurgery resident after a night of running 12 units of Fresh-frozen Plasma that the patient was complaining of being short of breath. He was as happy as I was that she was able to complain. I gave the ordered Lasix and went home. On my next shift, that evening, I paged the same resident to report that the pt (a lady in her late 80's) was sexually harassing me, patting the bed beside her and saying, "Hop in, big fella!" Again, with were both pleased with this mental status change after a pretty bad bleed. But, no, I didn't actually document getting hit on (which was only playful).

[RhiaRN75, RN]

"patient is confused no matter what the doctor says. the doctor wasn't in the room wrestling with him all damned night!"

my hero! i haven't the nerve to write that.

i'll add that to my "things i'll say/do the week before retirement" list.

[rotteluvr31, ADN, RN]

oh my gosh - another laugh when I needed it. Thanks so much for sharing.

[Code_VSA]

I always chart exactly what the patient says, tone of voice, all of any curse words, etc.

From one fat old broad to another.....I did get a big kick out of this thread!

[CountyRat]

"patient claimed that three young, beautiful women and one fat old broad -- that would be me -- "strapped him down and fondled his privates" all night long"

Wow, where do I go to get a job at a hospital that is so well staffed that four nurses have time to do anything "all night long" but run and keep everyone alive until morning! Sign me up!

[fdorgham]

Hah! I love this!! If there are any job openings, let me in on it! What a way to keep things interesting!

[silverbat]

I was reading nurses notes from the previous shift, and noticed that an LPN stufent had charted: "Iv INFILTRATING as ordered". OH MY! I knew she meant infusing, but what would an attorney do with that piece of charting!!!!

[harleyridingirl]

I tried to tell a nurse that her father who was my patient in ICU was confused. She got angry and said, "No, he's NOT, he's like that ALL the time!"

[NurseEmRN]

I documented several times about a pt who was very inappropriate with me and my CNA's. He eventually decided to assault me, and I reported him. When talking to my other coworkers, they also revealed he had done some inappropriate things, but they "blew off" the comments and arm caresses, etc. I explained to them that this encourages the pt to push more boundaries until someone ( ME!!) get assaulted. It looks like I am the only one he was inappropriate with, and if this goes to court, there is no written evidence of his behaviour with all staff.

Same goes for a pt's mother who constantly yelled at and verbally abused staff. I was the only one to document her interaction with me( appropriately -not what I really felt !!). If all the nurses she abused would document this behaviour, when the lawsuit comes ( because we could not adeqautely care for her daughter no matter what) then it will show her actions were irrational, and not just ONE time with ONE nurse.

[Kayartea]

One of my favorites was when one of our brand new foreign fellows charted in the H&P "complains of of frequency ass burning micturation".

Of course, he meant associated with burning micturation. It's amazing how much fun the absence of a punctuation mark can engender in tired nurses.

[guppy_one]

I am a little concerned about the woman who thought "nuts" and "balls" are the appropriate medical terms. Just because English wasnt her first language is a poor excuse.