Patient Phone Call Documentation: Fill & Download for Free

During this time, I have been conducting phone visits for free. As doctors, of course, we don’t get payment for phone calls. We don’t have telemedicine set up, so I simply document the phone call. People are scared, and many of them are very sick. So I talk on the phone, and really I can get a lot of the information that I need from the telephone and a review of the chart. Also, I typically pester my patients to get home blood pressure monitors, home pulse oximeters, and blood glucose monitors. I can figure out a lot with their data from home. I am glad that I did this, now it is coming in handy.So, today, I spent 90% of my day on the telephone, doing phone health for people who did not want to leave their homes. I called in prescriptions, and I ordered xrays and laboratory tests if I thought that was fairly urgent. We will probably need to lay off much of our staff for the next few weeks, with just us doing what we can on the phone.I also ended up seeing patients who really should have been seen in the emergency room, because they had fairly serious problems. But they were afraid to go to the emergency room, due to concerns about infected people being there. So I had to work out ways to do “emergency room level” testing in a way that did not require a visit to the ER. This is somewhat inappropriate, but it was the best I could do given the patients’ concerns.Also had to speak to people on the phone who have cancer and other serious problems such as HIV and liver problems and who know they will die if they get ill, and they know they might also die if they can’t get their usual treatments. It is not a fun time. Plus there was concern about a couple of potential staff exposures. If we get quarantined, things will go downhill in a hurry for our patients.Stable people getting refills is a no-brainer of courseEDIT: I am now getting reimbursed for telehealth.

It’s not so much that I was upset, but frustrated. I am a forensic psychiatric nurse. I no longer work on the floor, but when I did, I worked in maximum security. We had a patient who was so challenging, he split his time between 2 facilities. I am a very patient, but this patient stretched my patience to the limits at times.One Friday night, I was the only RN with 5 psychiatric techs on a maximum security unit that was supposed to have 2 RN’s along with 6 techs. That night, I had a patient who became actively suicidal;therefore per protocol he needed to have his room stripped along with all of his clothes wearing only a canvas jumpsuit, along with a 1:1 staff escort. I lost one psychiatric tech to run the floor.In addition, I had 2 seclusions for aggressions, which required MD orders along with injury reports. One had punched a wall and broke his hand and the other….well lets just say he inserted an object in a place where something should never be inserted. It was his MO to get to go to the hospital. The protocol for seclusion required a staff be at the door to monitor the patient for the first hour. Again, I lost two psychiatric techs for one of the busiest hours of the night, which left 2 techs to run the whole unit. This was incredibly dangerous and could’ve resulted in disaster. Due to the lack of staff in the facility as a whole, there was no extra assistance, plus I also had the rest of the 18 patients that needed to be cared for.I can’t even verbalize the amount of pressure, stress, and chaos. I had so many phone calls, orders that I could never get a task finished. This happened around 3 years ago, but we still weren’t completely computerized so everything was done by hand, which included faxes, copies, phone calls, and documentation in multiple places.This is when the difficult patient decided that he was not getting enough attention, and decided to complain of chest pain. He often did this every Friday evening or when he felt that he needed attention. Unfortunately, he had several cardiac diagnoses therefore every complaint was taken seriously. We were required to send him to the hospital with every complaint. He was the third person on the unit that I sent that Friday night.As I said, he was attention-seeking, and asking every five minutes when the ambulance would arrive to take him, either because his symptoms were increasing, or he had a new complaint. While waiting for the ambulance, we were required to complete VS q15min and head to toe assessments q30min. His VS and assessment were always WNL. Before any patient leaves, we had to copy most of the patient’s chart, which we could only do with the fax machine that was about 10 years old. We also had to send records to the hospital, and somehow find a way to give report to an RN in the ER.So, that was my night and difficult patient in a nutshell. I suppose that was the most frustrating interaction I had with him, but he tended to always be a little frustrating and required a lot of your time.Needless to say I didn’t get out of work that night till almost 1:30 AM, about 2 hours after my shift was done. The facility decided not to pay me the OT because I wasn’t efficient enough. I had to sit down with my supervisor to discuss how the situation could’ve been handled better. I didn’t even fight it because I knew it was a losing battle.

I was named in a lawsuit along with two other nurses and one surgeon as we were all on duty the day the alleged incident ocurred.The plaintiff was woman who was hospitalized for severe injuries after a snowmobiling accident. When she was caught trespassing on private land she tried to get away by going under the fence which earned her a fractured hyoid bone and collapsed lung.Well after discharge I received a phone call at home that I was being named in a lawsuit. The accusation was that this woman had fallen while she was in my care, breaking her back and jaw. I was extremely distressed as anyone would be when she is told that she is being sued. What really bothered me was that I could not remember the incident. Those were significant injuries which I should have remembered.At this point in her recovery she has been out of ICU for several days. Her chest tube is out. She is up independently and able to walk in the hall. She still has the tracheostomy. On the night in question I woke her up at 10pm for her scheduled trach care which she refused and went back to sleep. I left the room and didn’t hear anything more from her.When the day nurse initially saw her the patient told the nurse that she had fallen the previous night not in an angry tone but in a “by the way” manner. The nurse completed the necessary paperwork and notifications.After I was sued, I went down to med records to review her chart. She continued to be up ad lib after the “fall”. There were no complaints of jaw or back pain. No related tests were ordered. No specialists were consulted. No abnormal assessments related to such injuries were documented. She went home a short time later.The wheels of justice turn slowly, and it was years before anyone in risk management contacted me. She told me that the plaintiff had switched attorneys which is always a good sign because it meant that the previous lawyer realized that he did not have a case. I was reassured that my charting covered me. I was given the hospital attorney’s card and told that he would be contacting me in a few days. He never did. I heard nothing more about the lawsuit.I am convinced that this patient never fell and got hurt.