I am crazy about writing nursing note narratives. It's not really a lost art, but rather a form of communication / documentation that has been cast to the wayside, because our Over-Lords have fashioned an easy out (Computer charting). Nurse got lazy! That's all it is.
I write, as if I am going to find myself in court, about 3 years from now. Those who read my notes, would agree to my statement. I write a narrative journal in a sense, on each patient I have that day. I have done that from the beginning of my career, until now, 35 years later.
Anybody who wants to know what happened on Tuesday, at 5pm, when Oscar (me) was that nurse, only needs to go to "Notes and Transcriptions"...........Nursing Progress Notes...........and you will find out, what procedural sheath of 22 French, was in what Femoral artery, and if it bled and how long, and what Doctor was called, and who the Echo Tech was and so on.........................that's how it still needs to be done!
Note Writer
I'm a nursing note
writer
That's my
declaration,
Like I'm writing
to the Jury
Describing fact
and causation,
Every single
interaction
For the patient I
observe,
In the final court
of law
I didn't drive off
the curve.
Go ahead, read my
notes
You'll know what
happened each time,
When Joe-Bob got
up
And slipped on his
slime,
And I called the
Doctor
And the Doctor
said:
For Gods sake,
keep Joe Bob
Tied down in his
bed!
Or something like
that
Back in the day,
when we could do it,
When Joe Bob broke
his leathers
After all, he
could chew it,
Whereas, you can
be sure
I documented it
all.........
You might try to
sue me
But I won't take
the fall.
In these EMR days
Half the Nurses,
they don't write,
They check boxes
and forms
And read their
phones half the night,
But three years
down the line
When Joe Bob's
case comes up in court,
They won't
remember a damn thing
They'll just
shake, whimper and snort.
Yes, Nursing is
very demanding
But I write, for
each one,
My job is to tell
their story
Everything that
was done,
During my short
contract
Their events, my
responsibility,
And if I am
questioned later
My notes are my
utility.
12/4/18
No comments:
Post a Comment