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.
I went into nursing later on after having worked in the business world. Most of the time what I wanted to say. " Why is so much of health care set up in such an inefficient way?" " "Why are we documenting so many senseless, mindless, unnecessary things that rob time away from actual patient care?"
I went into nursing later on after having worked in the business world. Most of the time what I wanted to say. " Why is so much of health care set up in such an inefficient way?" " "Why are we documenting so many senseless, mindless, unnecessary things that rob time away from actual patient care?"
"Patient is a poor historian." = Patient is prescribed an ACE inhibitor, insulin and an inhaler but denies any medical history.
I'm reminded of some of the claimants my husband's dealt with over the years (he helps ppl file for disability). Hubby looks through their history, and asks them about their high blood pressure and their diabetes. They insist they "don't have" HBP/diabetes. My husband says, "Really? Then why are you on (HBP meds) and (diabetes meds)?" The claimant smiles brightly and says, "Oh! I *used* to have HBP/diabetes, but since I started on those meds, I don't have them anymore!"
What I wanted to say: pt is an idiot to keep returning for the same problem and refuses to follow up appropriately. He is wasting our time and resources.
What I said: pt returns for cocaine related chest pain for the 3rd time in as many months. No EKG changes, no elevated enzymes, no subjective findings to attribute presentation.
My husband once had a claimant who had something like 27 cocaine-related heart admissions in 24 weeks. He still couldn't get a clue.
Specializes in Psych (25 years), Medical (15 years).
"Why are we documenting so many senseless, mindless, unnecessary things that rob time away from actual patient care?"
One reason is because the accreditation and benefitting agencies need to stay afloat and have a reason for existence.
"Your assessments don't have an area that identifies the patient as a high risk for hangnails or papercuts" they say.
Bam! Administrators respond with a knee jerk reflex and nursing assessments then have drop down indicators for identifying high risk hangnail and possible papercut patients!
Specializes in Psych (25 years), Medical (15 years).
"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?
There was a high maintenance recidivistic psych patient who gets admitted through ER after smoking crack and claims to be suicidal. During one stay, he became upset with me when I "provided reality orientation".
He angrily informed me,"I'm not coming back here!"
Specializes in Psych (25 years), Medical (15 years).
One of my favorite notes I wrote within the past year was about a woman with pseudoseizures who conveniently went unresponsive as I tried to get her from the wheelchair to the stretcher. I gently whispered in her ear to get up that I knew she was not seizing at the moment.
She abruptly opened her eyes widely and yelled at me for telling her to quit faking.
You cured her, WKShadow! And without an invasive intervention!
I once cured a patient with pseudoseizures by a technique known as "laying on of hands". Some call it "sternal rub".
The patient immediately regained consciousness and exclaimed, "That hurt! I was having a seizure!"
Specializes in Psych (25 years), Medical (15 years).
"Patient is aware of the risks and benefits, including but not limited to---" - Patient knows they're making a poor choice and doesn't give a flying fruit basket.
Asked patient what measures we can try besides dilaudid, morphine, Norco, or fentanyl as none of these can be given for another two hours. Patient refused all other measures and continued pushing call light for narcotics every 5 minutes.
ethics&modesty
15 Posts
Ruby - your post brought ne to tears i was laughing so hard. Bobby T.