hospitals – Sheila Dougal

Nursing : A ministry of dignity

I’m up late. Tomorrow I’ll start working night shifts at the hospital where I work as an Acute Rehabilitation nurse. It’s just temporary through the end of the year when I’ll complete my BSN… finally ( it only took 18 years).

I’m up late doing research for my Capstone project. It’s about how the nurses at my hospital can implement change to prevent our often elderly patients from acquiring pressure injuries (A.K.A. bedsores). And all this research has me thinking about what motivates nurses and how much healthcare in the U.S. depends on nurses.

Nursing is not a lesser version of practicing medicine. It’s a way of honoring the dignity and worth of another human being through giving wholistic care, instruction and resources for the person’s good. But so often, especially bedside nurses, loose sight of what it is they do, or rather they’re disillusioned by what they do.

The pressure on bedside nurses from hospital managers and administrators is to perform complex, fast-paced deliver of tasks and medications and education… endless requirements all documented to a T in 12 hours. The pressure from the bed (patients and family members) is often (not always- there are many thankful and inspiring people in those beds) to provide 5 star resort pampering. The pressure from our peers is often to act like we have it all together, like we don’t need help, like we can do anything. And all this pressure has many nurses loosing sight of what’s really important: human dignity. Our own, and our patients’.

This is where, for me, being a Christian nurse is so freeing. The yoke of hospital nursing in America is heavy, but Jesus’ yoke is light.

I don’t have to please the system, or please the patient even, I have to honor the Imago Dei in every one of my patients. When I make human dignity the aim of my nursing care, all the rules and regs and complaints fall like broken chains.

There is a healthcare crisis in the U.S. The fastest growing portion of the population are over 65 and many don’t have the resources or support to get the care needed to live and die with dignity. There is a shortage of nurses in the U.S. and many are part of that fast-growing retirement age. Chronic disease plagues half of our populous and many don’t get the treatments, medications, appointments and care they need. Center for Medicaid Services has lists and codes and rules that make navigating the healthcare system a daunting task. Amidst the dark maze of U.S. healthcare, nurses who value human dignity are respites of light.

Dear nurse, I know you feel overwhelmed. I do too. But stop and remind yourself, you’re a nurse. Not a doctor. Not a medication-technician. And you’re not a slave to the hospital or healthcare company you work for. You’re a nurse. A minister of help, hope and heart. You are a minister of dignity. Our healthcare system is a mess, but that person in that bed, no matter how nice or how cranky, how dependent on drugs or how debilitated with cancer, is a person made in the image of God. And like Daniel Darling wrote referencing his surprising response to Horton Hears a Who:

‘Yes,’ I thought, “every person really is a… person, no matter what their usefulness to society, no matter how seemingly insignificant they are, no matter what their stature.”
A person’s a person. What a thought for our strange and confused age. – Daniel Darling, The Dignity Revolution. p.14

I’m not a medication technician. I’m a nurse.

I met him at the time clock.

“How are you?”

“Great, now.” He smiled reaching for the barcode side of his badge to swipe out.

It was the end of our shifts. He worked the observation unit where patients stay in the hospital for less than 24 hours. He admitted 4, discharged 4, so had a total of 12 patients that shift. “Not that bad actually…” he reasoned. Usually it was more like 16 or 18 patients a shift with the rapid turnover, or thoroughput as the hospital administrators like to call it.

We walked into the elevator together lamenting the fact that we have degrees in nursing-which is a theory of practicing healthcare that is born out of service and caring for the whole person- but we are defacto medication technicians.

We pass meds, answer call lights, document idividualized plans of care, Braden scores, BMAT’s, NIH scales, head to toe physical assesments (that we’re basically filling in the blanks for cause we literally had 55 seconds in the room before being called out to talk to Dr. So and So), intake and output, vital signs (because we’re short on nursing assistants), Functional Independence Measurement scores (in perfect detail after noon and before the end of the shift because Medicare thinks we’re forecasting care if we capture it in a chart before noon. Newsflash Medicare: WE ARE FORECASTING. IT’S THE ONLY WAY THIS REQUIREMENT WILL GET DONE)… I could go on and on. But all the time we spend with our patients is mostly given to documentation and passing meds…. we barely get time to squeeze in a really good asessment, much less time to educate our patients, listen to them, and collaborate with others for their good.

We’re nurses, not medication aides. But at the end of a 12 hour shift of being interrupted every 55 seconds we cling to making sure our patients all got their medications and all the required charting is done as the evidence that we did something meaningful all day. And we hate it. We don’t want to just pass meds and chart. We want to nurse.

Nursing is not an assistant to practicing medicine. Nursing is a way of practicing healthcare. It’s wholistic. It listens. It touches. It serves. It cares. It instructs. It encourages. It finds resources. It researches. It collaborates. It leads. It values the image of God in people.

The healthcare delivery system in America, especially in hospitals, lays a heavy burden on nurses’ shoulders. But if we can see the value of what we’re doing and go to the person in that bed in need of a person to help them get better and go home, or die with dignity, we’ll drop the baggage of the U.S. healthcare system and become lightbearers.

At the end of a long day spent, I pray I can say my focus was the person, not the system.

I’m not a medication technician. I’m a nurse.

Nurses, we are our patients

Friday the 13th I became a patient at the hospital where I work. I had a robotic total hysterectomy with salpingectomy and cystoscopy. After years of battling endometriosis, and recently bleeding, pain and fibroid issues I decided it was time for the worn out organ to go.

Being on the other side of the patient/nurse relationship is strange. I joked on social media that I felt like a spy. I did, but not with intentions of busting anyone. Just more like an undercover agent gathering intel. I noticed some things I’ll take with me with when I go back to work. The main thing I noticed was the obvious: I was the patient, someone else was my nurse. I bring this up because when you’re the nurse, it’s easy to distance yourself from the patient and when you have to be the patient you get a reminder of how human we all are. Nurses, we are our patients. Our bodies get diseases and we have surgeries, we need medical care. We don’t seek out medical care as much as non-nurses. We tend to care for our own needs and avoid being the patient.

There are many problems in healthcare and nurses feel the weight of those problems. But what motivates us to do the difficult work we do is a genuine care and concern for the health and well-being of people. And those people include us. Nurses, we need to take care of our bodies, because our bodies are the ones caring for other bodies. And we need to embrace, encourage, guide and teach new nurses, because they are taking care of us!

When I was admitted to pre-op on Friday a PCA, new to pre-op checked me in, gave me a warm, anti-microbial sponge bath, and then she realized I didn’t have an armband on. She ran to the desk to print one, verified my name and date of birth and put it on… inside out. She apologized, I assured her it was no big deal. She fixed it and we went on to verifying what I was having done, applying my SCD’s (which by the way I love, and want to own… it’s like a leg massage while you sleep!). Then the overhead announcement came that the hospital is in “downtime”, which means the computers don’t work and you’ll have to document everything on paper. The nurse and PCA bemoaned the fact that this was going to mess their day up, and rushed to print labels so they could draw my blood before the printer stopped working.

In the midst of the nurse and PCA discussing the trouble with their downtime situation, the anesthesiologist popped his head in from behind the curtain, said he’d be doing my anesthesia, had to go to another case first but would be back. He’s the one I was praying for. If the anesthesiologist doesn’t get it right, things go bad fast.

Once the IV was in and the labels were printed and the circulating nurse for the operating room spoke with me, verifying all my important information, the gynecologist doing my hysterectomy came in and sat down on my bed, put her hand on my leg and assured me of what was going to happen and how long and such. My husband left my side with a kiss on the forehead and versed being pushed into my veins. I remember the O.R. Getting on the table, a mask on my face, hearing the voice of my doctor and nurse telling me to go to the beach for awhile. And the next thing I knew I was shivering, moaning and hurting in the recovery room.

In the recovery room for 4 hours, waiting for a bed to open up in the hospital for me, I was in and out of shivering episodes, and drugged sleep. Somewhere in there my doctor talked to me about the surgery… I vaguely remember images on a paper and the word endometriosis.

When I got to my room on the postpartum unit, the pain, shivering and nausea had taken over. Between dry heaves, my nurse asked me the admission profile questions, the lab came in to draw my blood, the CNA took my vital signs, two nurses came to check out my skin and look at my incision sites and noticed that my left hand was very swollen- my IV had infiltrated. And then I had to pee. That didn’t go so good. In fact it didn’t go at all. The nurse called my physician, attempted to drain my bladder with a straight cath (attempted, is the key word here… 3 times to be exact). For the next two hours I tried to breath, reposition myself in some tollerable position in that bed with those flat, plastic pillows and text family members and friends who were wondering how I was. The nurse tried a couple times to start an IV with no success, so the house supervisor came to my rescue with one swift poke to my left bicep. By 9 pm, I was throwing up, still couldn’t pee, three more attempts later, a congregant of nurses had a successfully placed a foley catheter so my bladder could empty. The last time I had that many nurse looking at that part of my body I was having a baby. Humbled, medicated, poked everywhere I could be, I hunkered in the fetal position and prayed for gas to pass, urine to flow and my pain to back off enough that I could sleep a few hours. I got two.

At 6 am, when the Foley catheter came out and the male student nurse came in with his preceptor, the countdown began: When I could pee, eat without puking and walk down the hall I could go home. By noon I had accomplished all three. The discharging nurse reviewed my medications, discharge instructions and precautions with me and my husband wheeled me to the car.

Things have improved tremendously in the past 24 hours. And I’ve been thinking a lot about how nursing is caring for other people. People like me. I’ve run across patients in the hospital who seem to forget their doctor’s and nurse’s are people just like them. They get sick, have headaches, fight diabetes, high blood pressure, endometriosis, cancer, have surgery. They don’t know all the answers. But they are in the position of doctor and nurse to help the person in the bed get to a place where they can go home and feel better. Nurse’s we need to remember our patients are people just like us. Patient’s your nurse is a person just like you. We all have needs at times that require the help of others. The nurses and doctors who cared for me weren’t perfect, but they were caring and did what they could to help me. And I’m so thankful! I needed their help.

When I go back to work in a few weeks I’ll be the nurse not the patient, but being the patient this past week has given me a more relaxed view of what I do. In all the pressure to perform it’s so important to give each other the grace, forgiveness and accountability imperfect people need. Patient’s need our help. And nurses are not perfect. But what we do for our fellow man to help them gain strength, function, dignity… it’s very God honoring. We nurses care for people made in the image of God. And sometimes we’re the people being cared for.

Burning out nurses are a seismographic reading of the coming tsunami in healthcare

It’s a buzz I hear every shift I work, “The hospital is short nurses and aides…” The tension on the unit is thick. Will there be enough nurses? Will I have to take more than 6 patients? Will I only have 1 CNA for my unit of 25 patients? Will I be asked to check my email, fix a missing code status, remove equipment from the hallways, be reminded to not violate HIPPA by leaving my notes at the nurse’s station face up? Will I be asked to be the team lead with a full load of patients, do an inservice on the unit, not leave the patient’s in the bathroom alone, make sure all my patients are happy, document the fall risk score in two different places now because the IT people changed the process again? I really could go on and on here. The tension and dissatisfaction of nurses who are working in stressful conditions already in burnout mode is at a fever pitch.

Currently working on my BSN, taking my evidence based practice class I’ve been asked to identify a practice problem in nursing and research for evidence that could help in changing practice for better patient outcomes. As I’m trying to narrow down my research, I feel like I’ve been asked to pick one problem out of a tumultuous, angry sea of problems. The problems in nursing are many. They point to greater problems in healthcare in general in the U.S. Like a seismograph is predicts earthquakes, the sense of impending doom amongst nurses in the U.S. is telling us that a tsunami of trouble is coming in healthcare. In fact we are already seeing it’s threatening waves.

With the mass of baby boomers in the U.S. who are elderly, have chronic disease and need ongoing healthcare, the health system in the U.S. doesn’t have enough nurses to provide the care this 50 million and growing population needs. Complications related to diabetes, heart disease, stroke and fall-related injuries lead to our hospitals being filled with elderly patients who often end up with hospital acquired infections and injuries . These infections and injuries are often traced to the lack of nurses.

Caring for our aging population in the hospital are nurses under the pressures of healthcare administration to fetch high patient satisfaction scores, prevent adverse patient outcomes, document every single interaction, intervention, assessment, plan, education (and more) of every patient he/she cares for, be highly educated, engaged, enthusiastic and all without the adequate staff, technology and resources they need in a busy 12 hour shift. We’re tired.

I know for me, I go to work every day praying that God will give me the wisdom and strength to care for my patients. I keep that my priority my entire shift. But throughout my shift, while my eyes are fixed on the prize of helping my patients heal and get out of the hospital better than when they came in, or die with dignity while they’re there, I’m being bombarded with complaints from patients who got oatmeal instead of cream of wheat and motions from family members who see me walking at a fast clip down the hall to retrieve a warm blanket for a cold patient and want me to come into their dad’s room cause he wants to go to the bathroom. I’m constantly being bombarded with a cacophony of call lights, vocera messages that there’s a doctor on the phone who wants to speak with me, written reminders at my computer from my manager to fix charting that was omitted from the previous shift, emails from IT, administrators, food services, the wound nurse, the fall prevention team, the engagement team, the joint leadership team… all wanting a piece of my attention and time.

If you’re a patient in the U.S. healthcare system, do as much as you can to advocate for yourself and your loved ones. Care for people around you- neighbors, friends. And if you’re in the hospital, pray for your nurse.

Nurses, we have to keep our focus on the what’s important. The system is in turmoil. A tsunami of patients with acute on chronic needs is coming our way, yes is already here. Let’s see the image of God in them, care for them with dignity and let all the attempts to put bandaids on the hemorrhage in our healthcare system not sway us from standing for what’s best for our health and the health of our patients. Sometimes that’s going to mean going to work praying, listening to an old lady tell you about her deceased husband, teaching a bilateral amputee how to slide on a board from his bed to his wheelchair, helping your fellow nurses and aides to help your incontinent, immobile patients get repositioned in bed so they don’t get a new pressure sore, and then after 13 long hours of a 12 hour shift walking back to your car praying for wisdom and strength to do it all over again the next day.

a 12 hour shift

(I have no pics of my work in rehab, so this image of working with a traumatic brain injury patient is from MSKTC.org )

I don’t write about my work as a R.N. very often, mostly because there’s so much that’s confidential. But today I feel like I just need to process what happened in the 13 hours I spent at the hospital. Maybe I’ll comprehend why my feet throb and my brain won’t shut off and go to sleep.

I don’t work in an E.R. or I.C.U. or any critical care conditions. I work in an acute rehab unit. Most nurses I work with yawn when they think about the nursing work in rehab. You only have to chart an assessment once a shift. No one’s on a monitor. You don’t have very many patient’s on I.V.’s. And for the most part, the patients are stable. So when I go home exhausted, feeling like I ran a marathon, my feet ache and I’m pretty sure I didn’t document what happened all day very well, I feel a little like breaking down what it is I did all day and saying, “I know it’s not critical care, but it’s rehabilitative care and that is very labor-intensive and teaching intensive.”

Tuesdays and Thursdays are conference days on my unit. Every Tuesday and Thursday the patients individual situations are reviewed in a closed-door meeting of the PPS Coordinator (I still don’t know exactly what that means but it’s the RN who deals with medicare and justifying patients’ needs for acute rehab), the Physiatrist (that’s the rehab physician), the OT (occupational therapist), PT (physical therapist), SLP (speech language pathologist), CM (case manager), RN clinical manager, and RN caring for the patient. Depending on how many patients are on the unit this meeting can take anywhere from 5 minutes to 2 hours. Today it took 2 + hours. This occurs while these same therapists and floor nurses are carrying a load of 4-6 patients on the floor that day and bouncing like ping pong balls in and out of the meeting to give their input on the patient, listen to the team’s input, and come up with a potential discharge date. Today I had 5 out of the 12 patients to bounce into this meeting to discuss, which meant my morning from 7 am to around 1pm went something like this:

1. Get report from two night shift nurses about my 4 patients and the 1 patient a float nurse (a nurse who came to care for patients on our floor but is not a staff member on our floor) has so I can know what’s going on with that patient since I will be doing the conference on that patient (float nurses can’t do conferences on patients on our floor).
2. Sign into the EMR (electronic medical record) and begin documenting that I received report and what the fall risk and mobility score my patients are and what education I will be doing with them that day.
3. Review the chart for orders, notes from doctors from the previous day, labs, vital signs, test results and medications that are due.
4. It’s now 8 am. Conference begins at 10:30.
5. Visit each of my patients briefly to introduce myself. Do a general assessment just by talking with them (Are they alert and oriented? Any pain? Any nausea? Are they constipated? Can they urinate? Do they need O2? Do they have any skin concerns/wounds?). Take some patients to the bathroom. Get some of them out of bed. Get some of them water. Get some of their breakfast trays set up. Call a CNA to come help pull someone up in bed.
6. It’s now 8:30 am. Two hours till conference.
7. Go to the Pyxis (the machine that dispenses the medications) and begin pulling 9 am medications for my patients. I pull the meds for 2 patients since they’re on the same hall, place them in different bags, label them and set out to look for a WOW (a rolling computer kiosk that I push around all day from room to room to give medications with and document my care of the patients) that works. (It’s about a 50% chance that the WOW you pick will loose it’s battery life halfway through scanning your patients meds so you hope to find the one you know keeps a charge).
8. Answer the phone. It’s been ringing the whole time I’ve been in the Pyxis room getting meds and everyone else is either on the phone already or in a patient’s room. It’s doctor so-and-so who wants to know who the nurse caring for patient such-and-such is? I put him on hold. Look for the assignment list. Find the patient and their assigned nurse on the list. Use the vocera (a clip-on phone device where anyone can get ahold of you anytime, anywhere as long as you’ve turned yours on and logged into it) to call the nurse who doesn’t have a vocera. I push my WOW to an outlet, plug it in and set out to find the nurse the doctor is holding for. Finding the nurse, I stop to answer 2 call lights (call lights are patients pushing the red “nurse” button on the remote in their bed to get a nurse to come to their room), take an empty breakfast tray out of a room per the patients request and help a patient to the bathroom.
9. It’s now 9:00 am. I start passing my medications.
10. In my first patients room I have a quick, easy assessment looking at wounds that are healing nicely, talking to a patient who’s alert and oriented and has no new problems or complaints. But I do make note to follow up with the doctor about a question the patient had. I pull out the meds, scanning the patients armband with a scanning wand exactly like the one in the self-checkout isle at Sam’s Club. It beeps. The right screen pops up. The computer confirms that I have the same patient that the patient reports to be by telling me their full name and birthday- I can proceed. I scan each medication telling the patient what it is and what it’s for if they don’t already know. The patient complains of constipation so I make a note to bring back a medication later to help with that. I ask if there’s anything else I can do and since there’s nothing I let them know I’ll be back to see them throughout the day and hand them their call light so they can reach me. On to the next patient.
11. It’s now 9:15am. My vocera goes off. Dr. So-and-So is on the phone for me. I push my WOW to an outlet, plug it in. Walk to the nurse’s station and answer the phone. I give the Dr. a report on their patient, hang up and return to my WOW. On to patient number 2.
12. In patient number 2’s room I find a lot more to do. The patient is in bed. The breakfast tray is on a bedside table 10 feet away from the bed, and the room is dark. I introduce myself. Ask if the patient would like to get up and eat breakfast (In rehab we don’t leave patients in bed for meals. All patients, if at all possible, get out of bed for all meals). I open the blinds to let some light in. Patient #2 would like to get up. I plug my WOW into the outlet in the patient’s room, take the medications with me and set out to find a CNA or willing RN to help me transfer the patient (who requires 2 people to assist with transferring from bed to chair). The nurse’s station is empty, a phone is ringing, and 2 call lights are going off. I answer the phone. Patient such-and-such’s family member would like to speak to the nurse caring for their loved one. I place the person on hold, vocera the nurse and converse with a doctor who showed up at the nurse’s station after exiting my patient’s room. We discuss some changes and I get orders for some thing’s he’d like nursing to do for his patient. I make a mental note and call for a CNA to help me with my patient. Together we transfer this patient from their bed to the wheelchair. I’ve performed some of my assessment in talking with the patient and transferring them. I complete the assessment with a listen to their heart, lungs and abdomen and a few orientation questions: What’s today’s date? Where are you? Why are you here? I go on to ask about pain or any other issues or complaints. The patient shares with me a couple of big concerns. I note them on my “brain” (a piece of paper I scratch notes on all day) and begin scanning the patient’s armband and medications. I discuss the plan of care for the day and the changes the doctor wants implemented. I ask if there’s anything else I can do before I leave and then exit the room with a promise to return every 2 hours to carry out the new treatment ordered by the doctor.
13. It’s now 9:50. I head to the Pyxis room to get medications for patients #3 and #4. On my way into patient #3’s room I’m flagged down by the WOC,RN (that’s the Wound, Ostomy, Continence RN) who would like me to assist her in the assessment of wounds and dressing changes in Patient #2’s room. I let her know I’ll meet her there in a few minutes. I continue into Patient #3’s room and perform my same routine of intro, asking questions, assessing the patients condition and discussing the plan of care for the day. This discussion included plans for discharge today and the patient’s concerns and questions about how it was going to happen. While discussing and assessing I was also scanning the patient’s armband and medications to give them quickly knowing I was needed in the other room to address wounds. I made quick notes on my “brain” about the patient’s requests for PRN meds and asked if there was anything else I could do. I left the room with a promise to return with the requested medications.
14. It’s now 10:10. Conference begins in 20 minutes and I still have a half a dozen wounds to address, another patient to give medications to and another patient (who wasn’t my assigned patient) to assess so I could give some input on that patient in conference.
15. I go back to Patient #2’s room, assist the wound RN in undressing and redressing wounds. We find more wounds that we were expecting. I leave the patients room to go gather more wound care supplies, return to the room to finish what we started and get called out of the room via my vocera 20 minutes into our care: They are ready to start the conference.
16. I leave the wound nurse to finish what she’s doing and head to the conference with my notes in hand. It’s 10:30.
17. 30 minutes later I emerge from the conference on my 1st of 5 patients and call for the next nurse on the list to trade me places. Their turn to discuss their patient. I leave the room with notes in hand about all the requests the doctor made for me to follow up and the concerns brought up by the therapy staff and case manager. I set my notes face-down at the nurse’s station and set out to patient #3’s room.

Ugh. I’m tired already and it’s only 11am on my recall of today’s events. What transpired from 11 am to 1 pm was a cacophony of call lights, phone calls, vocera calls, medications scanned and given, following up on things not done yet that were noted on the original visit to patient’s rooms, intermingled with 4 more interruptions to go to the conference room and discuss my patient with the team. By 1 pm the conferencing of our patients was over, I was hungry, and way behind on charting.

In nursing there’s a saying: If it isn’t charted, it didn’t happen. Every assessment, every discussion (which is education), every intervention, every phone call to or from a doctor, every order, every vital sign, every medication, every treatment, every meal, every drink, every void, every stool, every transfer, every change in position…every interaction with a patient must be charted in the electronic medical record- or it didn’t happen. I estimate it takes about 4 hours of accumulated time to chart throughout the day. Most of it is interrupted charting. Interrupted to care for patients. Which must be charted.

I took a lunch at about 2 pm with only my assessments charted. Half hour later I returned to work on my patient’s discharge from the hospital. The case manger is usually the person who takes care of arranging the medical equipment, transportation, follow up appointments and facilities needed for a patient’s discharge. But sometimes those things fall on the floor nurse. Today they fell on me. From 2 to 7 pm, when my patient finally discharged from the hospital, I was on the phone with various entities to work out complications in the discharge plans and needs so this patient could leave and go safely. Those 5 hours were interrupted with giving medications, addressing wounds and assisting with my other patients needs along with answering call lights and more phone calls.

At 7pm when the night shift showed up and I said goodbye to my patient who finally got to leave the hospital, I hadn’t even begun documenting all that was required for me to chart from the shift. I gave report to the night shift nurses and then sat down to chart. An hour and 15 minutes later I was done. I had completed the required documentation… I think. (Did I mention that in a rehab unit there is an entire additional hour or so of charting that medicare requires from nurses to justify a patient’s stay in rehab?)

8:15ish PM I clock out. Walk to my car. Drive home exhausted. And when I’ve said goodnight to my kids, showered and sat down to unwind before I go to bed, I feel my throbbing feet and recognize the questions still running through my mind, and I think, “What happened today??!”

If you’re ever a patient in the hospital you should know your nurse is probably running her tale off. If you see her at the nurse’s station on a computer, she’s not sitting there doing nothing. She’s trying to make sure what she really did today is documented so that if anyone goes looking, it happened. If you have a good nurse she won’t mind if you ask her what medications you’re taking or question what she’s giving you. She’ll be glad you are being an advocate for yourself and gladly tell you what you’re taking and answer any questions you have. She’ll listen to you and talk with you and make sure you’re doing ok and then she’ll have to go back to her computer and punch keys and scroll through doctor’s notes to make sure she’s recording what really happened and doing what really needs to be done that day to make sure you get better.

I would really like someone to invent a charting robot.