2013 is the year we quit talking and start doing. If you are bold enough. you could be the proud owner of a Haydel Consulting Services flash drive. Be the envy of your friends with this ultra sophisticated, data base storage device that has been proven secure and reliable and goes where you go. Better than a cloud drive, the HCS drive doesn’t rain, snow or block your sunshine. Mobile storage for mobile nurses! All you have to do is attempt the documentation challenge presented below and enter your response in the comments section.
Challenge: Consider the following information and write a brief but thorough narrative describing your care. Your vital signs and assessment are performed and documented.
You are on call on a Saturday evening when a physician calls you about a patient. You have never seen this patient but open up your computer and see that the patient is a 78 year old female with diabetes. Secondary diagnoses include congestive heart failure, kidney disease and Alzheimer’s Disease.
The physician is concerned because the patient’s daughter called and said her mother was ‘acting out really bad’. He wants a blood sugar and lab done to ensure her lytes are in range. He also wants to know if she may be hypoxic and asks you to weigh the patient and get a pulse ox reading.
Your assessment is unremarkable. Her fingerstick blood sugar after supper was 162. Her pulse ox is 99 and her weight is recorded at one pound less than the prior week. Vitals are good and the patient appears to be in her usual state of health other than the behavioral disturbances. You ask the daughter what prompted her to call the MD and she reported that her Mother did fine all day. She was confused but pleasant and content. Her mother listened to music and folded a laundry basket of dish towels while the daughter cooked for a family gathering later in the week.
At about 6:30, the patient began showing signs of agitation. Nothing seemed to work to quiet her anxiety. The daughter gave her some xanax as ordered and tried to reason with her mother. Twice the daughter had to go outside and bring her mother back indoors. The daughter is genuinely afraid she will have to put her mother in a home.
So, you’ve drawn the lab and performed the assessment. What else might help this patient and her daughter? How do you document it?
The winner will be announced a week from Friday. That means that if you have case conference or staff meeting between now and then, you can all practice ten days in a row. There is no limit to the number of entries but they all must be original. The grand prize will be chosen from all entries so it really doesn’t matter if you can’t chart a skill to save your life. You can still win and after next Friday, you will know how to document at least one skill.