Thursday, December 1, 2011

Charting Fail

We have an agency nurse on day shift right now who is- let's say- a little special. We've had a couple of great agency nurses, but as a general rule, we don't exactly get the cream of the crop. This guys is right up there with the winner who finally got fired for getting in a screaming match with one of our NPs about whether it was kosher to give a gram of Rocephin mixed with 10 mls of sterile water IV push. Yeah.
Anyway, despite the fact that everyone who else who came here while we were still using paper charting a while back was appalled that we were so provincial and dated, this guy, who is allegedly a seasoned nurse, seems to be terrified of our computer charting. Since all but a handful of our portable computers broke within the first 2 weeks of getting them, it's not uncommon for us to use a piece of scratch paper while getting an ambulance started and put all the information in the computer later, key statement being put the information in the computer later.
If a patient has gotten there within an hour before shift change, this guy writes a bunch of shit in random places on a blank piece of printer paper and then hands it to you during report like, yeah, here's my assessment, bye. So, not only are you stuck with all the other crap he inevitably leaves you, but his charting too. It's whatever to me- I just collect all the information myself and put it in when I triaged the damn patient, because I don't really have time to sit down and decipher this Son of Sam looking shit that is supposed to be nursing notes. I got some time to look over some of this charting (?) the other day when I was helping a friend catch up, and it was pretty amusing. Among the vital signs and medical history, there were all these notes- I'm guessing observations or reports from EMS, one of which read "pt is tacky".
Tacky? Please elaborate, sir. Were you referring to her attitude or her manner of dress? I mean, she wasn't super cooperative, but I'm pretty sure the nursing home dressed her, so you should at least give her a pass on wearing a nightgown this early in the day. Certainly not any more People of Wal-Mart worthy than any of our other patients. Oh... did you mean "tachy?" Oh, okay. Yeah, maybe the avoiding putting stuff in the permanent medical record route is your best bet when possible.

7 comments:

  1. this makes me wonder... why do people i know have a hard time finding nursing jobs for lack of experience? to me, lack of experience in nursing is FAR better than "incompetant nurse"

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  2. Not certain how you guys did your paper charting but in my home health job, we do paper charting in a narrative note format. Ughhh. I'd probably find something like "pt done been tacky at 1130." Assuming that I can read the notes at all.

    That, or I'll read through a note and it's the same XYZ that the previous nurse writes on all her notes. Then mom will come in and be like "oh nurse had to take the baby of the ventilator and bag her for a while and all the vent settings got changed and oh the back-up ventilator is broken." Thanks for mentioning that.

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  3. "Son of Sam looking shit" LOL! Good oneA1

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  4. I'm an agency nurse that primarily works ER, because I've worked ER for years, but as a general rule, agency nurses suck. I've had another agency nurse look at me and say, "I'm only here to help," not knowing that I was also an agency nurse, not regular hospital staff. Ummm...no...you're getting paid $10-15/hour more than their staff becaue you're supposed to be experienced enough to handle the shift that YOU ACCEPTED. Ugh. Incompetency drives me nuts. Good part about agency nurses: you can get them a big fat "Do Not Return" if they are more of a burden than a help.

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    Replies
    1. The grammar on this post is a DISGRACE.

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  5. Yes, I also agree - "Son of Sam looking shit" - GOLDEN! (stores in mental file for future use)

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  6. Tacky...I love it! I am a new follower.

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