Tuesday, November 01, 2011
wonder where your nurse is?
Dear Jane/John Q. Public ER patient:
Wonder where your nurse is?
That's me over at the desk. I am filling in hundreds of blanks on the computer. I am doing the charting on the computer around your visit.
I'm sure you understand I have to chart things about what is wrong with you, the meds I give you etc. What you don't understand is that there is WAY more to the story than that.
When you come in to triage, I am charting what is wrong with you yes.. oh but that is just the beginning. Your complaint is a miniscule part of what I do in triage.
In triage I am charting:
your allergies and your reaction to them
you height and weight
your level of pain and describing exactly what kind of pain you have
whether you have flu symptoms
whether you have had TB
whether you have had MRSA, VRE, etc
whether you have any implanted devices and what they are
your last tetanus short
our acuity - I choose from 1-5 as to how sick you are
your last period
whether you need an interpeter
how you got here
are you ambulatory, in a wheelchair?
who brought you
When I assess you in your room:
a head to toe assessment
a screening of: verbal or physical violence, your risk for suicide, do you have money for food, are there any barriers to your understanding of your care
your meds, their dose, how often you take them, when did you last take them
during your visit:
Depending on your acuity, your vital signs every 15 min to 1 hour
all meds I give you
your level of pain and a description of it
your IV solution start and stop times
any medication infusion start and stop time
tests you have and when you went and came back
anything that happens to you during your visit
something about your family
conscious sedation checklist and education and charting every 15 minutes for 1 hour after
a long checklist of neurological symptoms, if you are having a stroke, a head bleed about every 15-30 minutes
if you are restrained, I chart a long checklist every 15 minutes
a complex blood administration checklist
specific charting around trauma
any intake and output you have
post cardiac arrest hypothermia protocol and all that goes with it
a strip of your cardiac rhythm
an assessment of your skin condition
any social worker visits
any mental health clinician visits
any MD specialist visit
your c collar and backboard info, wound irrigation and bandage
all bruises and scrapes
If you are critical:
rapid sequence intubation charting
size of endotracheal tube, where it is, ventilation settings
bipap and its settting
your infusions and any changes I make in them
your NG tube
use of rapid infuser, fluid warmer, bair hugger, chest tubes, central lines,
CVP lines, arterial lines, etc.
blood, platelet, plasma infusion
critical lab results
other stuff I can't remember
your understanding of instructions
whether you understand what your medication is for and possible side effects
your level of pain
where are you going
how you will get there
if you had narcs who will take you home
your condition at transfer
your medication infusions at transfer
your level of pain at transfer
your IVs at transfer
where your belongings are
is your family here
who is transferring you
do you have monitor, 02 at transfer
I am reading the 5-10 emails I get daily about policy and procedure changes,
hospital events, emails from VP of nursing, CEO, manager, other nurses.
I am answering calls from lab, xray, MRI, CT, other departments, your family members and friends, etc.
I am trying to read the 10 education things I get quarterly that I am supposed to complete on work time.
So if you feel like we don't see each other much during your visit, this is why. Healthcare's priority has gone from you to this.
P.S. Your doctor other there, increasing in ERs, has a person who does their computer charting for them, just so you know...
Posted by girlvet at 2:03 PM