What Nurses really Want to Say When They Chart

A peek into what we are really thinking when we jot down that clinical note... Nurses General Nursing Article

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.

Specializes in Pediatrics/Developmental Pediatrics/Research/psych.

"Patient seen ambulating through the unit. Requests medications to be brought to bedside because of inability to walk. Client is reeducate do regarding medication times, treatment goals and unit rules."

This is a malingerer. I will not play those games. She can definitely walk to the station. If she says she fell, I will not take the responsibility.

Specializes in Oncology.

"Report given to oncoming RN" Peace out, until next time folks

Specializes in Pediatric.

"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.

"Patient resting comfortably and noted with deep, unlabored resps" -Patient didn't bother us all night

"Patient exhibiting signs and symptoms consistent with labile mood; not amenable to staff redirection attempts" -Patient is acting bat crap crazy and there's nothing we can do about it... For now.

Specializes in Pediatric.

"High lab value received; paged on call hospitalist and awaiting return call. Endorsed to oncoming nurse." -I tried my best so don't blame me if the next shift drops the ball!

Specializes in critical care.

This reminds me of a conversation I had with a surgeon when I asked for parameters that might warrant calling him over night. He said, "don't contact me. Contact Doctor Aware."

Anytime you EVER see the words "no new orders received" in my charting, it means one of two things:

1. The patient is being unbelievably impossible regarding something either dangerous or not at all medically indicated, and thankfully the MD agrees

2. The hospitalist is being an asshat

"No orders received" is my polite way of saying, "are you effing kidding me," and other variations of, "what the eff, man."

As for the rest of my list, AN will asterisk out enough words that it would make no sense.

Specializes in Flight Nursing, Emergency, Forensics, SANE, Trauma.

"Patient calling out of room, repeatedly, for nurse. Upon looking in on patient, found patient in no distress, lying quietly in bed. Upon physically walking into room and engaging patient, patient began to writhe in bed, screaming, and demanding 'something better than toradol!'" Patient is a drama llama, also should get 4 cc's of NorSal, fast push or titrated to nurse comfort.

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.
This reminds me of a conversation I had with a surgeon when I asked for parameters that might warrant calling him over night. He said, "don't contact me. Contact Doctor Aware."

Anytime you EVER see the words "no new orders received" in my charting, it means one of two things:

1. The patient is being unbelievably impossible regarding something either dangerous or not at all medically indicated, and thankfully the MD agrees

2. The hospitalist is being an asshat

"No orders received" is my polite way of saying, "are you effing kidding me," and other variations of, "what the eff, man."

As for the rest of my list, AN will asterisk out enough words that it would make no sense.

I can neither confirm nor deny that my charting recently said, "Attending informed of sepsis criteria; stated not concerned because patient not hypoxic".

Fever of 103 untouched by regular doses of Tylenol, chills, sweats, aches, shallow/rapid breathing, significant drop in BP (I wanna say it was around 105/50), O2 sat = 90%...

I can also neither confirm nor deny that within five minutes of my charting about his lack of interest, the attending came and personally checked on the patient.

:sarcastic:

Specializes in LTC, Acute care.
That's so cool!!!! You have a "do not admit" list??? I want one!!!!

I didn't know we had one at my hospital either until our pt (frequent flier and all) went ballistic and threatened to deal with a doc and make sure he was dead, he earned himself a " do not admit" to our hospital. He could go to the other branches of our hospital but not our particular one. Most nurses heaved a sigh of relief and exchanged some not so subtle high fives when we heard that.

Specializes in critical care.
I can neither confirm nor deny that my charting recently said, "Attending informed of sepsis criteria; stated not concerned because patient not hypoxic".

Fever of 103 untouched by regular doses of Tylenol, chills, sweats, aches, shallow/rapid breathing, significant drop in BP (I wanna say it was around 105/50), O2 sat = 90%...

I can also neither confirm nor deny that within five minutes of my charting about his lack of interest, the attending came and personally checked on the patient.

:sarcastic:

That would get a big ol' NO ORDERS RECEIVED from me!

you made my evening. heeheheheee

Specializes in Med-Surg, Emergency, CEN.

A FLACC scale on a verbal pt...

seeking!

"Patient displaying agitation, running around the unit, using expletives turning on all the faucets and flushing all the commodes. Patient tackled another patient and brought him down to the floor. Physician notified, order placed for oral Haldol and Ativan. Medication administered. Continue to monitor patient. 1:1 observation ordered. "

Translation: Patient out of control, dangerous to self and others. Physician afraid to use all means to control because he is afraid of the patient and doesn't want to violate his rights

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