Creative Charting

Nursing chart review. Patient is a 65 year old female, brought to ER after becoming disruptive in workshop at community mental health center. Delusional and screaming about being “injected with climaxes” from staff at mental health center. Sexually preoccupied with manager at workshop. Upon chart review, staff in hospital spent fifteen minutes considering ways of patenting the climax injections and shared dreams of early retirement.

3/21/09 0700-1530

@ 0915

Assumed care of patient. Elaine is demanding and entitled. Has repeatedly put call light on, insisting staff “serve me breakfast in bed!” Limits set with use of call light, explanation of not being on medical floor offered, rules about all patients having to eat in the dining room given. Stubborn and obstinate. Refused breakfast and stated she would starve before she would eat in the dining room. Patient’s breakfast enjoyed by staff.

@0935

Refused morning meds. Stated she would not take them until manager from workshop was there and demanded staff bring him to her immediately. Explanation of visiting hours given. Patient then stated, “My boobs need him before then!”

@ 1045

Elaine came to nurse’s station, demanding her breakfast. Informed that she had missed her opportunity to have breakfast and reminded of rules regarding eating in rooms. Told that she would be offered lunch at 1230 in the dining room. Angrily stomped away from desk, warning staff that if they “don’t do what I tell you to do, I won’t do anything you want me to do, either!” Was overheard by staff to be asking housekeeper for soap. Housekeeper directed to send patient to desk to get her needs met.

@ 1105

Elaine returned to nurse’s station, requesting “some soap that won’t make me horny.” Was given bottle of liquid soap. No complaints of horniness as of this writing.

@1245

Eating lunch in dining room with peers. Complaining loudly about quality of food. Patient was reminded that she was former employee of this hospital in dietary department.

@ 1320

Came to desk with complaint of headache. Offered Motrin 400 mg. Refused, stating she needed Tylenol. Patient informed that Tylenol was not available for her, as she had a Tylenol allergy. Angrily informed staff that they were ‘not authorized to give me a Tylenol allergy!” and that staff needed to review what their practice allowed them to do to a patient.

@ 1440

Elaine came to desk and stated that she needed to use “someone’s cell phone.” Was informed that cell phone use was not allowed on unit and that she could use patient phone located in lounge area behind her. Became angry and stated that she did not use patient phones and we’d better give in to her demands.

@1500

Elaine returned to desk and warned staff that if we didn’t let her use our cell phones, she would, “call you-know-who!” Was informed that it was well within her rights to call whomever she pleased.

@ 1510

Observed to be using patient phone, possibly calling you-know-who.

@1530

Care of patient turned over to next shift

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2 responses to “Creative Charting

  1. don’t know how you folks can put up with this stuff — you have my utmost respect

    • Thanks, but this type of patient really isn’t as difficult as most. They’re just people with problems like the rest of us. Keeping a sense of humor really helps, too!

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