Sunday, March 11, 2012

In Your Own Words

One approach to charting I've really embraced in my short time in nursing is the use of quotes. Especially when someone is acting foolish. I've found it's pretty difficult to truly capture exactly how crazy some of these fools are when they come in, but their own words really help paint the picture.
For example, by all means, come to my hospital and request IV pain medicine. Please. I will put in the chart exactly how you requested pain medicine in your IV today. I will chart how many times you called me while you were waiting to be evaluated and every obscenity you used. I will also chart how much Fanta and Cheetos you were eating at that time, and how many times I encouraged you to stop eating with your 10/10 abdominal pain. Finally, when you call me a "skanky white bitch" and tell me "I'll kick your little ass in the parking lot"because the doctor didn't order you that D medicine you got last time, well. One, that shit is now in your permanent medical record, boo. Have fun reporting the hospital like you keep threatening to do. I hope you do report us, and I hope they pull your chart and see how violent and psychotic you really are. Two, hi, I believe that was a threat to the staff? Yeah, meet the police. They will be escorting your ass off the hospital grounds now, bye. Funny how the folks that get brought back to the room via wheelchair are suddenly able to walk independently with a brisk and steady gait once going to jail is part of the picture.
As an added bonus, quotations are just fun for everyone and are the next best thing to a dramatic reenactment you can get. Use as often as possible for the entertainment of your coworkers. Thus concludes my inservice on charting. Reading this will give you approximately 30 seconds of CE credit.

7 comments:

  1. What always cracks me up is when they pretend not to remember the name of that medicine they want. Yeah right.
    That and post partum vag deliveries c/o of pain so bad and requesting that "oxy med." Oxycodone? "No the other one." You want oxycontin because you just delivered a baby? Yeah pretty much can guarantee that isn't going to happen.

    ReplyDelete
  2. Yeah, I always quote . If later they complain about their lack of treatment, management can readthe play-by-play.

    ReplyDelete
  3. I especially like incorporating a note on how effectively migraineurs are managing to use the text feature on their cells in their darkened room while they continue to have debilitating 10/10 pain, thier iced coffee procured from the drive-through enroute to the ER by their side. Even though they are REALLY nauseous. Yeah. Only the D medicine works.

    ReplyDelete
  4. I love quotation marks, for all those reasons and more. I will also quote family members in the chart. Just for added reading fun

    ReplyDelete
  5. I work on an ortho floor, so we also use a lot of the D and the O. Occasionally I'll have a patient who'll say something like "I don't like to take that stuff, I'll only ask for it if I really need it" (and even more occasionally they're actually being sincere and not trying some tripe-reverse psychology bullshit). When that happens it's all I can do not to jump on their bed and kiss them on the mouth.

    But yes, quote the shit out of that shit. If they think it's OK to speak to people that way then in my opinion it's A-OK to include their words in the medical record. (Some people think you shouldn't, here's a good post and discussion on the same: http://pakazoid.blogspot.com/2011/03/too-much-charting.html)

    ReplyDelete
  6. Definitely an important point on charting, using quotations and observations. Seems like both can go a long way!

    ReplyDelete
  7. Hahaha, Heidi- awesome visual. Thanks for that!

    ReplyDelete