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.
How do you nicely chart "patient is filthy and stinks to high heaven", "is quiet until they see me, and then become talented, moaning, pain med seeking actors", and "the family needs to leave, they are causing problems"? I manage it, but would like to hear others thoughts :)
Social Services evaluation requested! (Dump...not fair really. Kind of joking...hee hee)
Hahaha. I guarantee that I chart a "no new orders received" at least once a shift. I also like to chart quotes from patients and/or family members when they are being completely inappropriate or disagree with the physicians orders/plan of care.
Parents refuse to have name and placed on child after multiple attempts to explain safety comcerns. Charge nurse aware, MD aware. Risk management aware.
"No orders received": Doctor X, good evening, how are you doing? Sorry bothering you, yua 'now, that protocol... yep, nothing is going on, yep, have a good night!"
(why on the green Earth I have to spend my time doing THAT?)
"continue to monitor": I was here. I truly was. And the old guy was still alive at that point. My word.
"family educated about (...)": one more upteenth time. Still does not seem to get it.
"patient/family informed about risks and benefits, decided to proceed with (...)": ... you will be highly edified. They will tell you in their Latin that your daughter is not well (Moliere, "Love is the best doctor", act II, scene 2).
(In plain English: they have no idea what it is all about, but it all sounds like a good idea).
"verbalized understanding of (...)": after making bad decisions for longer than I am alive, it suddenly dawned upon him?
Specializes in LTC, CPR instructor, First aid instructor..
How nurses really feel when stressed is NOT allowed, so there should be a creative new language that can be posted for nurses to learn so they will be able to sound off withoug using vulgarity.
I think what makes me most crazy is when a patient and their family expect us to "fix" their loved one, yet refuse or defy every medical intervention proposed to them. Yet it is still the hospital's fault (or more accurately, the nurse's fault) that said loved one has not been healed. I often would like to say "So, then exactly WHY did you come to this facility for help if you will not allow us to do perform any of the things we know will help your loved one." Really, why DO people come to the hospital if they don't want any help we have to offer?
I think what makes me most crazy is when a patient and their family expect us to "fix" their loved one, yet refuse or defy every medical intervention proposed to them. Yet it is still the hospital's fault (or more accurately, the nurse's fault) that said loved one has not been healed. I often would like to say "So, then exactly WHY did you come to this facility for help if you will not allow us to do perform any of the things we know will help your loved one." Really, why DO people come to the hospital if they don't want any help we have to offer?
...Dilaudid.
Haha, jk. But really. And Dr. Google makes things fun, huh?
I think what makes me most crazy is when a patient and their family expect us to "fix" their loved one, yet refuse or defy every medical intervention proposed to them. Yet it is still the hospital's fault (or more accurately, the nurse's fault) that said loved one has not been healed. I often would like to say "So, then exactly WHY did you come to this facility for help if you will not allow us to do perform any of the things we know will help your loved one." Really, why DO people come to the hospital if they don't want any help we have to offer?
So agree! Have had this experience many times. "You won't let us do what we know will help....so why are you here?". Very often they are angry as if we should just "fix" the problem, but NOT in any way we know how to do. Oh my goodness, I so can relate.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
How do you nicely chart "patient is filthy and stinks to high heaven", "is quiet until they see me, and then become talented, moaning, pain med seeking actors", and "the family needs to leave, they are causing problems"? I manage it, but would like to hear others thoughts :)
"Pt has disheveled appearance and is somewhat malodorous." Or if you want to be really PC: "Pt is hygienically-challenged." "Pt observed using cellphone with calm modulated voice. On my entering the room pt immediately began to moan and vocalize with increasing volume and emotion." "Family appears to have difficulty coping with patient's situation; they were encouraged to seek respite for themselves away from stressful hospital environment."
BeenThere2012, ASN, RN
863 Posts
Social Services evaluation requested! (Dump...not fair really. Kind of joking...hee hee)