I Love My Job
I love my job. By nature I am curious. Opening a clinical record and reading about the history of patient and the interactions between patient and nurse satisfies my urge to be nosey.
Sometimes, however, I feel as though I am being punished. Impeccable charting directly from a teaching manual can bore a person to tears. Consider the following two examples of charting about an elderly gentleman with lung cancer, completely in denial and usually intoxicated.
- Patient remains non-compliant with medication routine exhibiting drug seeking behavior. Notified MD. No new orders.
- PRN visit for complaints of anorexia. Patient states to nurse, “I called you because I can’t eat. Now you are asking me why I can’t eat. Y’all are F***ing crazy! Tell that doctor I ain’t going back until I get my pills.”
While the first note is completely accurate it really doesn’t paint a picture of the patient.
The second example tells me a whole lot more. The patient uses colorful language to be sure. The one quote tells me that he may be extremely difficult to teach. I know that it will be challenging to get this patient to buy into compliance. In other words, ‘I get the picture’. And that picture comes more accurately from the patient’s own words than anything a nurse will ever learn out of a book.
In another agency, I was reading the visit note from a nurse had gone to visit a patient in an assisted living community. The opening sentence in the note explained that the patient was complaining because the green beans at lunch were not cooked the way she preferred.
Consider how much information is in that one sentence. The patient is complaining about vegetables. Patients who are in serious pain or have no appetite due to illness usually don’t care about green beans. And this patient is not apathetic, a common symptom of depression. She really did care about her green beans. And it is apparent that this patient remembered what she ate and how it was prepared so short term memory is intact. Again, the nurse has painted a picture I can see and understand.
Compare that to, “Patient denies pain or discomfort. Reports lunch was eaten prior to nurse arrival.”
In our efforts to be professional, concise and ‘appropriate’, we often forget the real purpose of clinical documentation. Effective communication between care providers enhances the quality of care given to patients. When reading the examples above, I know I am better able to pick up care following the more colorful examples than the ones that read like a nursing text book.