Never chart this

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Was just doing (yet another) mandatory education bit. Just had to share. Thankfully I did this, otherwise I might have charted these very things, since I never went to nursing school and like to shoot off my mouth on a legally binding document... ;)

•This patient is drunk.

•This patient is looney-tunes.

•This patient is a pervert.

•This patient is nasty.

•This patient smells like he has never taken a bath in his life.

Direct quotes in documentation are the best. You can be factual while letting their own words do the more, ah, colorful, describing.

And... it allows you THIS scrumptious (internal, innocent thought) satisfaction:

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Specializes in LTC, home health, critical care, pulmonary nursing.

Ah, Ruby, I've missed you! What issue could there possibly be? That's pure gold!

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I personally loooooove charting direct quotes from clients who are being purposefully mean to me. Not sure if that's an accepted practice where everyone else is, but at my current job it's welcomed, fully spelled-out curse words and everything. I find it very satisfying especially if the visit was challenging.

My job also loves direct quotes whenever possible when charting, especially if the patient is aggressive or combative.

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Specializes in "Wound care - geriatric care.

The minute I suspect a pt will be a problem (of some sort) I begin to write a book about him/her. Every hostile thing they say, non compliant atitudes, disrespectful behavior, any behavior. I document everything that is out of line that they do. By the time they call the ombudsman and report you to the state, they can say whatever they want. They'll have no ground, no case. End of story, I love nurses notes - our best friends.

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This patient appears impaired and emits an odor of alcohol and is also exhibiting behaviors that could possibly benefit from a psych consult. Appears sexually preoccupied and may benefit from increased hygiene due to the numerous rodents inhabiting his person.:eek:

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This patient is drunk.

Yeah i know it sucks, you can put ETOH positive as verified by the MD

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