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.
