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Tuesday, May 26, 2009

Nursing Notes

In nursing school we were taught that if it isn't charted, it didn't happen. It's the safest way to think about charting. Document EVERYTHING. A chart is a legal record of care given, and it needs to be complete and as accurate as possible.

I, like most nurses, spend a lot of time documenting, especially writing progress notes each shift. A lot goes into notes, and there are good notes, and bad notes, but they take up time no matter how you do them.

Today as I wrote out my notes, I was struck by how little of our day to day life actually goes into one of those notes*.

S: Pt c/o pain 9/10 knees. "They ache." Denies GI distress. Denies SOB. No other complaints voiced.
O: Ambulating slowly, steady gait. VSS. No change in mental status. Good eye contact. Affect appropriate to mood. Bilat LE examined, no change in CSM. No edema noted. No change in temperature. Patient rec'd all morning meds a/o. Requested and received motrin 600mg at 8:15am for pain.

A/P: Patient reported good effect with motrin one hour later. CTM for pain, offer heat packs and motrin per care plan. Monitor for GI distress r/t antiretroviral therapy. Monitor for s/s infection, monitor temp q shift.

This might be my note on a patient for an entire 8 hour shift. Bam. Chart closed, note's done unless I need to append it.

It's a pretty good note. There's a lot in there. The prn med is documented and I even recorded the effect of the prn. In the plan section I referenced an HIV status to give a clearer picture of the client. It's a good note.

But it doesn't take into account how this patient sat and told me all about the dog he had growing up.
Or maybe it was a woman. And maybe she told me about her kids as I poured out her meds, and how much she misses them.

It doesn't record how I maybe I witnessed him helping another patient around in a wheelchair.

Or how maybe I saw her praying when she thought I couldn't see.

There will never be a record of the staff's caring reaction to a small woman whose world collapsed with one phone call. Or documentation of how much one staff member or another hopes that this man won't relapse and AWOL and come back drunk all over again.

There's nowhere to write down our hopes, our fears, or our love.

Of course... there's also nowhere to write down our frustrations. And rightly so. A legal document is no place for griping. An overly needy patient will be documented by a prudent nurse as being "anxious," and rude responses at the med cart may get called "mood disturbances," if the patient is lucky and "behavioral issues," if she isn't.

The chart needs to be neat, succinct, objective and accurate.
You can write "patient vocalized positive feelings about seeing husband today," but you probably shouldn't write "her eyes are shining with hope."

And you should write "continue to offer emotional support following death of family member, referral to mental health recommended," in the Plan instead of
"please be careful with this patient's heart. It is broken."

It makes sense. No complaints here. It makes the patient's medical record easy to read, follow and reference.

It was just something about writing so many in a quick row today that made me see how very small a note really is. It's far too small to embody the people it serves. It barely contains any people at all.

* This note is fictional and any resemblance it has to any patient real or imagined is unintentional. It was merely meant to illustrate what a SOAP note looks like for readers who may have never seen or read one.

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