Yesterday was very trying. Not because anything super serious was going on, but because I had 4 patients, all at once, that needed a bunch of stuff, all at once.
I had 3 seriously ill pts, the docs were taking their sweet time requesting admits. I get a new 1, c/o chest pain.
She was brought back, vss, EKG nsr. Md said it was ok to monitor until room opens up. She proceeds to go outside and smoke, and smoke, and smoke. Nobody charted.
Long story short, there was more work put into this pt I swear than my sickies. It became quite clear to me, that this was a genuine, I'll c/o chest pain so I get IV pain medications. Don't get me wrong, as frustrating as it is, you gotta prove it's not an MI. I get that. But the things coming out of her mouth, the demands, everything... And I'm attempting to chart it all up.. Every coworker walks by, sees the name and says 'oh ya, she's here every other day'
I can't believe that this is the 1st time she's behaved like this. There's no documentation. She's flat out complaining because dr so n so isn't on and they always give dilaudid. I challenge the doc who orders the morphine and they tell me that they have to treat it like an MI.
Not even 10 mins after I give her her iv med, she says take the iv out, I'm going home. She complained when I diluted her morphine, then flat out tells me as I'm giving it that she was gonna wanna leave right after.
So I ask. What does documentation get you?