Part Three Taking notes
One of the main duties of a nurse in a medical facility is charting. From the minute you meet a patient you begin writing, asking questions, filling out forms. After about an hour or so you have become well acquainted with the patient, his past medical history, his family's medical history, and current problems. Some people become quite aggravated with this process, others enjoy it. It is the job of the nurse to make it as painless as possible.
My father recently went to a doctor in a building that houses several doctors’ offices. He went in, filled out several sheets of paper, giving them every bit of information including his shoe size and favorite color (not really. he just felt that way). Immediately after he had finished he was sent to a physical therapist in another office a few doors down. When he entered the office, he was handed another stack of forms to fill out asking the same information. Well...needless to say my father refused to spend more time answering the same questions and told them to either get a copy from the other Doctor, or he was going home.
HIPPA laws require that nobody has access to your medical records but you and your physician, unless you give permission of course. The best way to handle a situation like this is simply to interview the patient. This will put the patient at ease, allow for one to one contact, and depending on penmanship, will allow you to read the information as well.
When I began taking care of my husband, I stopped charting, didn't feel the need. I mean, it was just him and me, and I was taking care of him every day. There was nobody to report to. It was not like there was another shift coming, or doctor's rounds. But then, my husband had to be deposed for his worker's compensation case. The lawyer for the company he worked for wanted specific information, such as dates and actions, which I of course couldn't provide. That day I went to the store, got a notebook and some page separators and started a medical chart on my husband, because I didn't want to be caught with my britches down again.
The first page of my chart was like a front page of a hospital chart. It listed his Name, Social Security number, address, phone number, insurance information, doctor's name and address, next of kin, known allergies and immunizations. The next section listed his medications. It included the name of the drug, strength of the drug, number of times to take it, and since he had multiple doctors, I included who prescribed the drug. I also had several copies so that each time he was transported to the hospital or doctor; I could simply pull a sheet and have all the information available, especially in emergency situations.
The next section included a list of supplies. It listed the name of the supply, the company that manufactured it, and the order number. I added a column to that page later listing the date ordered and received when we were switched to a different provider, and we had problems getting orders in.
Next was a section on Doctor visits and hospitalizations. It included the name of the doctor, date, reason for the visit, and outcome of the visit.
Since my husband was incontinent, and used a catheter, the next section was for input and output. For this section I printed out a calendar for the month. I would put the total for each day, on the day of the month it occurred. Now you are probably wondering, how could she possibly remember everything for the whole day to write it on the calendar? Well...I printed out a weekly calendar and placed it on the refrigerator. Every time I got a drink, I would simply write it on that day. At the end of the day, I totaled it all up. Since my husband's urine was measured in cc's I converted the fluids he drank into cc's as well. This is not as hard as it sounds. For my husband, he drank sprites in a can. I poured them into a large plastic cup with a cap and straw so he wouldn’t dump them in the bed. 1 can drink is 350 cc's (this information is on the can). I made a chart from 1 to 6 cans, and what the total would be. That way, I wouldn't have to be doing a lot of adding. 1 cup is 250 cc's, and if you drink something that is bottled it will tell you what the amount is. Milliliters and cc's are the same thing. I would also put a check mark on the days he had a bowel movement, if there was more than one, I would just put a check mark for each one. This is good for making sure there is no constipation or impaction.
The last section in my "chart" is for notes. I will talk more about that next time. I don’t want to overload you with too much information. So I will let you digest this and see you again soon.
In the hospital, some nurse’s chart by a method called SOAP. This stands for Subjective, what the patient tells you; Objective, which includes actual facts such as vital signs, lab values; Assessment, findings during an actual examination; and planning, measures that are planned to fix the current problem. Of course when you are taking notes at home, it is not necessary to get so technical.
Last time I gave you the information for Objective charting. That included medication history, input and output history, supplies, and doctor visits. The last section, notes, will include subjective and assessment information. The most important part of gathering information for this section is the interview. Now...I’m not saying you need to be Barbara Walters with a list of question that eventually make someone cry. It's simply having a simple conversation with your loved one. While this needs to be done daily, you don’t have to actually write notes daily, just write when there is a change in their condition or behavior. A typical start to your interview can begin something like this:
"Good Morning! How are you today?"
This question will orient someone to the time of day, and will give you subjective information...such as...Well I feel fine, or, I could be better.
If you get the first response, then you could ask, "How did you sleep?" If you get the second response, ask “is something bothering you." or "How could you be better?"
Communication with your family member is not only important to determine if there is a problem going on, but also its just important for your family member to have communication with someone, to be able to share thoughts, feelings and problems. Finding out quickly if there is a change in their status will enable you to get them the help they need faster so that the problem will be corrected sooner.
My husband became bedridden a month after his 50th birthday. He had gotten a decubitus ulcer (bed sore) on his back side after sitting on the wrong wheelchair cushion for too long. We had spent the weekend attending his middle son's wedding, and he was not able to transfer well from his chair to the bed. He had no other problems, no medical diseases such as high blood pressure or breathing problems or dementia. He was just paralyzed. We tried for months to get his worker's compensation insurance company to provide a lift to transfer him from the bed to his chair, but they refused. After 8 months of lying in the bed I should have been alerted to the bugs my husband kept insisting he saw on the walls and ceiling. Well...he was a big jokester, loved playing pranks on people, so I just put it off to him trying to trick me. I also knew that the house was free from any kind of bugs, so I wasn't concerned about that, however every time he would point out a "bug" to me, I would just tell him it was just a spot on the wall, or a speck of dust. He never believed me, so I would bring other people in there to confirm to him there were no bugs in the room. I should have been alerted to the fact that there was a change in his mental status. It wasn't long after the sightings of the bugs, that he developed a fever, became difficult to awaken and had to be rushed to the emergency room. He was diagnosed with a very bad kidney infection, which affected his blood, making him septic, and he was also diagnosed with pneumonia. I noted this in his chart, so the next time he saw bugs, I was able to get help faster and he was only hospitalized for a week instead of for a month like the previous time. However the looks I got from the hospital staff were a bit amusing when the reason for bringing him to the hospital was because he saw bugs!
Other things you need to write about in your notes are new medications. When a doctor writes a new medication, you need to write the date, what the medication is, who prescribed it, what it is for, and how it is working, or if there are any adverse effects. The pharmacy will give you a list of side effects for your medication, so you can be alert for any of those particular signs as well as differences that aren't on the list.
When writing notes, as I said, you don't need to make an entry every day, however when you do make entries, it is very important to mark the date and time of the entry for future reference, or if some lawyer wants to know. When a change in condition does occur, be sure to document it. An example would be something like:
4/18/11 8:00 am. Skin hot to touch, temp 101, 2 Tylenol given, cool wash clothes placed on forehead.
10:00 temp 101, doctor notified. Instructed to give plenty of fluids and check again in 2 hours. Water given and continue placing cool clothes on forehead.
12:00 temp 98.6
Writing this information down will not only keep a record of the problem, but will also help establish a record in case it should happen again. This helps to recognize a pattern and possibly detect a reason why it continues to occur.
You don’t have to be technical in your wording, but whenever you notice a problem, keep a record of what you do to fix the problem. Bowel movements are another problem, not only with bedridden people but with all elderly folks. It is very important to recognize if there has not been a bowel movement in a day or two. You don't want to have an impaction develop. That is not an ordeal you would want anyone to go through! Keep a record of what measures you use, such as provide laxatives, suppositories or enema's, and what the result was, such as no bm seen or bm noted.
Writing notes is a very individual process. Just like writing a letter or entries in a journal or diary. The important thing is to keep a record. If you notice a regular occurrence such as frequent increasing temperatures, or frequent patterns of constipation, you can alert the doctor and new solutions can be tried to prevent them from happening.
Medical Chart Notes (joke)
1. Patient has two teenage children, but no other abnormalities.
2. Patient has chest pain if she lies on her left side for over a year.
3. On the second day, the knee was better, and then on the third day it disappeared.
4. The patient is tearful and crying constantly. She also appears to be depressed.
5. The patient has been depressed since she began seeing me in 1993.
6. Discharge status: Alive, but without my permission.
7. Healthy-appearing decrepit 69-year old male, mentally alert but forgetful.
8. The patient refused autopsy.
9. The patient has no previous history of suicides.
10. Patient has left white blood cells at another hospital.
11. Patient's medical history has been remarkably insignificant with only a 40-pound weight gain in the last three days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. Between you and me, we ought to be able to get this lady pregnant.
14. She is numb from her toes down.
15. While in ER, she was examined, x-rated and sent home.
16. The skin was moist and dry.
17. Occasional, constant, infrequent headaches.
18. Patient was alert and unresponsive.
19. She stated that she had been constipated for most of her life until she got a divorce.
20. Rectal examination revealed a normal-size thyroid.
21. I saw your patient today, who is still under our car for physical therapy.
22. The lab test indicated abnormal lover function.
23. The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
24. Skin: somewhat pale but present.
25. The pelvic exam will be done later on the floor.
26. Patient was seen in consultation by Dr. ____, who felt we should sit on the abdomen and I agree.
27. Large brown stool ambulating in the hall.
28. She has no rigors or shaking chills, but her husband states she was hot in bed last night.
29. Patient was found in bed with her power mower
