TD-sometimes I just forget things. What happened in March, April and May seems like a lifetime ago. The trip to UNC just vanished from my memory.
I wonder if she went tried to get pain meds from Duke that night and was denied which is why she went to UNC. It would be very revealing to see her discharge papers. What meds, if any, was she discharged on? Advils? Anything stronger?
If I was her Nurse and if (speculating only) she was aking for pain meds far and beyond what her pain level should be (ie faking, and we are generally a good judge) I would document each time she asked for pain meds, my notification of the MD, and his response. Something like:
c/o pain in such & such area. Rates a whatever on scale from 1-10. Dr aware. [Next line would be an order from the doctor if he ordered anything]
I would also document a request(s) for a prescription prior to discharge. If she was unhappy with what the doctor prescribed, I would also document that.
I'd love to read her charts at Duke and UNC.
A reminder of what Joe Neff yesterday asked us to do...
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or Flexiril - presents with a sprain neck - and then she offers, (I'm guessing) Flexiril is what they gave me last time and it worked.
The N&O said her main complaint was Neck Pain.
Flexiril and Liquor may have been her thing at that time.