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(Mis)adventures in nursing documentation

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By: Fidelindo Lim, DNP, CCRN

Recently, I found myself in a lighthearted social gathering of like-minded strangers sipping colorful drinks (it was after 4 PM). As expected, the conversation turned to, “What do you do for work?” Tongue-in-cheek, I said “I’m a writer.” The natural follow-up question was, “What do you write?” Jocularly, I replied, “I write emails…lots of them. Everyday.” Now—and probably for forever—sending, reading, and replying to electronic mails and texts is the barometer of working. It’s the unashamed proxy of productivity or busy work. This communication hyperthermia has no remission in sight. Contemporary clinical nursing work came of age with charting as we know it. This led to the adage: If you didn’t write it, you didn’t do it. The cynical reinterpretation is: If it is written, assume it was done. But is it really?

WNL (Within normal limits, or we never listened?)

While working as a per diem nurse educator at a hospital that has since closed, I noticed that none of the nurses had a stethoscope around their neck when they made their initial assessment. Like an earworm, the puzzling question repeated in my head: If the nurses did not use a stethoscope, how come they documented that the lungs were “clear to auscultation”? I don’t suppose they rolled cardboard up into a tube and pressed one end on the patient’s chest and the other end to their ear to hear bronchovesicular sounds. The same goes for heart and bowel sounds, as well as bruits. I hope my comrades-in-scrubs can forgive me for implying that what was written is at odds with what actually happened. I imagine there is a lot more that goes into a head-to-toe assessment, and it transpires between the ears—the nurse’s brain. I envision that in the dark recesses of the nurses’ locker is a patinated stethoscope, perpetually on-call, and ready for use as the need arises.

Funny and sometimes lyrical

Looking back at my 19 years as a staff nurse, I considered writing the progress notes as a form of reflection-on-action, a backward knowing glance to make sense of what I had done. I self-debriefed as I wrote my notes. This realization appealed to the serious side of me. As a habit, I was also fond of reading the notes of other team members. This allowed me to appreciate the good work of my colleagues, and to synchronize my nursing actions with the overall plan of care. I particularly liked reading the notes of the chaplain—they were refreshingly non-medical. The unintended side effect of reading other staffer’s notes is that they sometimes allowed for some welcomed levity. A brief respite from hard day’s work. Consider these actual examples:

“She ate 40% of her meal tray.”

“Voided soft brown stools.”

“Noted to have bades secretions.”

“Foley is amber.”

“Other than pregnancy, the patient had no issues.”

“AM care done after lunch.”

These snippets reminded me that questionable grammar and uncertain spellings are forgivable, and one should not take work too seriously. On the other side of the spectrum, I’ve also read notes that were witty and lyrical. A particular standout was a medical intern’s notes of a patient’s reason for admission to rule out atrial fibrillation. It read: “The patient said ‘Imagine there is a small bird in your chest. It is beating its wings so fast and wants to fly out of there.’” The jargoners among us would have written “palpitations due to AF with RVR.” The verbatim transcription of the patient’s own words allowed us to take in their experience from their perspective. This exercise enhances the clinician’s narrative competence to respond to patient stories. When we combine narrative competence with asking the patient if they truly understand their medical scenario and what matters to them, we move closer to achieving patient-centered outcomes.

Have you read?

Perhaps this is just me, but I have a feeling that before the dawn of electronic health records, the staff read more of one another’s progress notes. This was partly because, literally, every practitioner wrote their notes on the same continuous pages. These days, the electronic health record is one of epic (pun intended) proportions (56 dropdown menus, anyone?). The attendant cognitive load fries the brain and ultimately leads to burnout. Look around in the nurse’s station—everyone is typing, hardly anyone is reading. Studies show that the amount of screen time is inversely proportional to the length of old-fashioned facetime with patients. Not reading or not having the time to read patient care notes ultimately impacts the way we “read” and “see” patients. When we appreciate our patients beyond the catalog of their medical-surgical histories, their lives become stories and patient care notes turn into time capsules.

A friend of mine who worked as a nurse in a long-term care facility in Germany told me that part of the admissions process is to ask a family member or caretaker to provide a lebenslauf, a curriculum vitae of the resident to be filed as part of the health record. Learning about the resident’s biography can renew our sense of wonder at the resilience older adults possess. It is a worthy consideration that knowing the lived experiences of our patients might convince us that real life cannot be reduced to clinical typology, and it is not always as clean, dry, and intact as a typical nurse’s note.

References

Charon R. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902. doi:10.1001/jama.286.15.1897

Szulewski A, Howes D, van Merriënboer JJG, Sweller J. From theory to practice: The application of cognitive load theory to the practice of medicine. Acad Med. 2021;96(1):24-30. doi:10.1097/ACM.0000000000003524

Fidelindo Lim is a clinical associate professor at New York University – Rory Meyers College of Nursing.

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