Never chart this

I saw an H&P where the physician said, "This patient is a mess."

I'll be honest the charting in our facility is so bad that if we were ever sued for not getting a patient fresh ice, we are covered, because it's the only thing that is ever documented.

It is exceedingly difficult, to get a psych placement for patients when nothing about their behavior is charted by nursing staff. It drives me nuts when I ask how "Mrs. Smith" is doing and they tell me about her talking to her parents who are dead and obviously not in the room and the tray she threw across the room. i go to pull up the chart and nothing is charted, for oh....three days. If they seem "oriented" when the psych pre-screener shows up, guess what? They are not getting placed.

I have had patients where they found roaches inside of clothing and dirt that was borderline mud in their hair...bathed the patient, charted the bath, but not the original condition of the patient. Very, very difficult conversation when APS shows up and tells you they have zero documentation of what you placed the call for.

Blows...my....mind.

This patient is nasty.

Ok, ok, ok. Professionalism aside, we've all thought this at one point in our careers about a patient or two, but the fact that someone actually charted this...:roflmao:

This made me laugh so hard my abdomen hurt. Sorry. I'm dead. Bahahahaha!

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.

YAAAAAAAAAAASSS! Direct quotes are oh so bloody satisfying!!!

I'll be honest the charting in our facility is so bad that if we were ever sued for not getting a patient fresh ice, we are covered, because it's the only thing that is ever documented.

It is exceedingly difficult, to get a psych placement for patients when nothing about their behavior is charted by nursing staff. It drives me nuts when I ask how "Mrs. Smith" is doing and they tell me about her talking to her parents who are dead and obviously not in the room and the tray she threw across the room. i go to pull up the chart and nothing is charted, for oh....three days. If they seem "oriented" when the psych pre-screener shows up, guess what? They are not getting placed.

I have had patients where they found roaches inside of clothing and dirt that was borderline mud in their hair...bathed the patient, charted the bath, but not the original condition of the patient. Very, very difficult conversation when APS shows up and tells you they have zero documentation of what you placed the call for.

Blows...my....mind.

Whoa where do you work that no one ever charts anything??? Is this LTC?

You forgot that 'pt continues to expose his genitals to staff, even after being requested to stop. Appears to be masturbating'

Im sorry, that actually made me laugh out loud

Can't get any more objective than that....

Probably not kosher. Although I did chart once that "Patient confused; attempting to converse with Alaris pump. States "That uppity bastard won't even talk to me." Strangely, my manager had some issues with that, although she agreed that it was descriptive.

Best factual uote of the day.

" That uppity bastard wont even talk to me "

:roflmao:

I suppose its not really funny if that is that persons true mental state, but it sounded funny at the time. I'd certainly have to look away for a moment....

I guess we just have to remember to chart objectively- I mean if thats what we see, that's what we see. And anything that the person says goes in quotes. I mean, pertinent things.

I just have to say, this thread has been a breath of fresh air and full of so many LOLs. Ahhh, I needed the good belly laughs. Thanks OP!

I have to disagree with the drunk and the bath. Nasty, pervert and loony has a lot of judgment and is also not very accurate. You can actually chart every single instance but just use another language.

i.e. instead of loony tunes you say...the patient was non compliant and confused, the pt refused to listen to RN directions, the patient refused to follow the RN instructions...so on and so forth

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.

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

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: