Having Fun with Documentation

[Davey Do]

There is a State of Illinois form called The Restriction of Rights that I've used from time to time for nearly 30 years, since I worked at Anomaly State Hospital, and still used yesterday. Basically, when a patient's rights are to be restricted, like the right to refuse medication, the form is completed, the patient is made aware, and receives a copy.

Like most government forms, it is terribly redundant. For example, there are no fewer than a half a dozen places to date and time it. There are four places to sign it!

We are to sign our full name and title in each of the four places. Obviously, the State of Illinois is okay with me giving my full name to, say, (with all due respect) an actively acting out psychotic ex-convict paranoid schizophrenic whose rights I am taking away!

No way.

"Davey Do RN" becomes D---- D- RN.

There is a place on the form for the patient whose rights are being taken away to have someone else notified of this legal process. We are also required to enter the full address of the one being notified. Some have designated, for example, their spouse, next of kin, or lawyer. Others have designated such deity entities as the Holy Spirit, Jesus, or God.

Under the address I just enter "Heaven".

Let's see the state of Illinois deliver a copy of the Restriction of Rights there!

Do you ever have any fun with documentation?

(Note: Immediate disqualification for "dropping the F bomb" due to its overuse.)

[mi_dreamin, BSN]

Among my favorites:

Pt grabbed scissors, held them up and loudly stated, " I want to see the son-of-a-***** who put those orders in!" Dr. Do-Nothing made aware.

Pt pushed sitter and ran into hallway, stated loudly, "I'm not ashamed, do you wanna see em!? Do you wanna see my *****!?I'll show you!" Security present.

Pt educated that SpO2 was too low to remove BiPAP and eat. Pt stated, "there has to be some compromise, it can't be all **** me, **** me **** me!" Pt then turned to face the window and refused to engage in further communication at this time. Will continue to monitor. (Sorry for the * bomb, I couldn't leave this one out and that's what he said)

Staff responded to pt's bed alarm. Pt stated she wanted to know who stole her whole lady parts. Genitalia intact upon assessment, will continue to monitor.

Pts heparin gtt turned off and left off by nightshift RN. Dr. Know-it-All made aware, states, "what do you want me to do about it? Ask the pharmacy, just follow the policy." Heparin gtt resumed.

And 3 of my favorite admitting diagnoses ever:

"Fell ill"

"Probably sick"

"I got pergernant"

(That's not a typo)

[beekee]

There may be a note in the chart that stated “MD paged per patient’s request for non-narcotic pain medication; instructed to ‘never call him again. Ever.’ No new orders received.”

[Davey Do]

1 hour ago, mi_dreamin said:

Dr. Do-Nothing made aware.

Donna's a cousin on my Dad's side who married a guy by the name of Ima Nothing.

You know- "Donna Do-Nothing"?

[Davey Do]

1 hour ago, beekee said:

“MD paged per patient’s request for non-narcotic pain medication; instructed to ‘never call him again. Ever.’

Standing orders really expedite patient care.

[Nunya, BSN]

Heaven! ? Maybe sometimes you could write "St Peter's Gate St." if you're feeling especially frisky or you're bored...