Document Everything!

1859: Observed patient's chest wall go up and then go down....second time in three minutes. Will mention this to oncoming shift.....maybe

Hee hee!

1859: Observed patient's chest wall go up and then go down....second time in three minutes. Will mention this to oncoming shift.....maybe

1902: patient telemetry currently showing asystole and "leads off". Monitor tech notified this RN a total of 16 times in last five minutes. Notified PCT. CN notified by monitor tech that patient leads presently off. Code blue called by monitor tech. MD aware. Will continue to assess.

1902: patient telemetry currently showing asystole and "leads off". Monitor tech notified this RN a total of 16 times in last five minutes. Notified PCT. CN notified by monitor tech that patient leads presently off. Code blue called by monitor tech. MD aware. Will continue to assess.

1926: MD on floor. Asks if anyone minds if TV is changed to the football game. Orders timeout.......but football team on TV does not respond. MD slams fist on patient's chest as football team fumbles the ball. Patient expels phone previously lodged in patient's throat. Collective sigh and :madface:noted. Will continue to ...umm...monitor

18:04. Patient resting quietly in bed. Alert and 0x3. PERRLA. Able to make needs known. Verbalizes no c/o. Respirations even and non-labored. Afebrile, with VS WNL. Skin warm, dry, pink and intact. Voids without difficulty, I=O. Last BM @ 0800. Repositions self approx q 2 hours to off load pressure. signed_________®Nurse, RN

I'm so glad that we have electronic charting now. What a pain it used to be to chart long hand on every. single. patient. all those years ago.

Well...within reason

1445 - Pt called, requested "ice water, with just a little ice and mostly water." Ice water provided to pt and placed on bedside table, within reach of pt. Straw placed in foam cup (300mL cup) at pt's request. Pt verbalized understanding of using the foam cup and straw to drink. Pt was assisted into high-fowlers position to drink. Pt states he has no other needs at this time.

1448 - Pillows fluffed for pt and sheets straightened. Pt stated, "I would like a new gown, please." Pt was assisted into new gown without incident. Pt stated, "I feel better now, thanks!" Will continue to monitor.

This thread is funny as heck, but I had a co-worker back in the early 80s who actually DID chart like this (yes, the same one whose patients ate "bowels of Jello").

1926: MD on floor. Asks if anyone minds if TV is changed to the football game. Orders timeout.......but football team on TV does not respond. MD slams fist on patient's chest as football team fumbles the ball. Patient expels phone previously lodged in patient's throat. Collective sigh and :madface:noted. Will continue to ...umm...monitor

Hahahahahahahaha!!!

Umm, are you plagiarizing the other notes? They all say "continue to monitor". (Or am I the only one who remembers that thread?)

I am the confused.

I am the confused.

That nurse told that nurse "I am the confused", this nurse states.

This may help.

Thank you! My brain broke at work today.

Thanks for the entertainment folks! :) This was hilarious.

As a side note, about documentation, in all reality: I'm so thankful I work in the OR. I don't miss the asinine things I had to figure out how to document as a floor nurse (I would be better at it now than I was then though).