Tonight I set a new record for myself; a mere twenty minutes after leaving report I uttered the familiar and dreaded question: "Has anyone seen my notes?"
For those of you who are not nurses, a nurse's notes are akin to what a bible is to a religious leader. They are that important and they contain that much crucial information. Prior to starting a shift the notes must be prepared and it appears almost ritualistic as each nurse has their own method and they repeat this method each and every shift. Some use a particular color of paper (I use orange);some use pre-printed forms made up on the computer, while others use multi-colored pens.
The information contained in the notes is fairly consistent from nurse to nurse. Room number, patient's name, age, gender, physician, diagnosis, date of admission, allergies, brief medical history, IV information, special treatments, and any other pertinent information. I also include times of medications, code status, and LBM (last bowel movement).
Carrying these notes is essentially carrying a summary of each patient in your pocket and are considered to be confidential information. As such, they are to be destroyed at the end of each shift. Tossing them in the garbage is not sufficient, they must go into the confidential waste. Any nurse who claims she has never lost her notes is lying; its part of being a nurse. Lost notes can be found in the oddest places; in charts, on patients' bedside tables, even in another nurse's pocket.
This time my notes magically appeared on the very same table where I had written them, and once safely back in my bulging scrub pockets, they stayed with me for the remainder of the shift.
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