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!
