Sunday, November 11, 2018

When The KARDEX Was King of Communication

Glen from Texas emailed me with a suggestion to write about my experiences with the nursing KARDEX which he advised is disappearing. I had no idea. How could something with so much utility just up and disappear?

Christians have their Bible, Jews have the Torah,  and nurses from a bygone era had their KARDEX. Named after a company that specialized in using index cards for data storage, KARDEXES  were the center piece of any nursing station. Patient charts come and go with whoever snatches them up, but the KARDEX is always front and center at any gathering of nurses. Change of shift report without this wonderful collection of data would be impossible.

The front and back of  a vintage KARDEX was a solid sheet of gunmetal grey steel with a piano hinge through the midsection. When you opened this hefty collection of vital information an audible, metallic  CLUNK would echo around the room. That harmonious sound reminded me of a church bell announcing that something important was about to happen. The flipping through the KARDEX index cards  made a gentle rustling sound like the wind blowing through a Midwest cornfield just before the combine moved in for harvest. What a contrast to the contemporary clicking, bleeping, and clacking of a computer keyboard. I loved this bit of KARDEX  acoustic candy because it was an auditory sign that my shift was over and more peaceful, restful times were ahead.

What information was included in the KARDEX?  Everything a nurse needed to know when providing patient care: demographics, treatments, medications, allergies, consults, code status,
 urine reductions, diet, surgery, I&Os, IVs, and  IM injection rotation sites (everyone received these painful ministrations and rotating the  sites distributed the pain over a larger area).  The patient's name and physician was written in ink, but everything else was written in pencil and unlike the medical record, subject to erasure. The Kardex was not a formal document and when the patient was discharged, the cards were ceremoniously tossed in the circular file. No HIPPA - No shredding.  Identity theft was unheard of.

From my blogging foolishness, I can attest to the fact that people say different things under the cloak of anonymity and the KARDEX was no different. I was a quiet and reserved scrub nurse and just look at the blowhard  I've become  with an anonymous blog.  Notations in the Kardex were not signed and nurses perfected a generic form of printing to avert handwriting analysis. This cloak of secrecy  promoted blunt and sometimes crude KARDEX entries.  KARDEX notations often liberated many a nurse's free spirit and foolishness was not too far away.

Nurses who came  before me often had to administer painful and unpleasant (to say the least) treatments and never took "no" for an answer. Rather than write that it was necessary to restrain or hold a patient to the bed for a treatment, code words were used. "Patient needs assistance maintaining proper position for enemas," sounds better than "restrain his arms to prevent fighting to dislodge  enema tube."  In pediatrics the youngsters often needed "help" to receive painful injections or treatments. Those old school nurses were a force to be reckoned with and their KARDEX entries sometimes bordered on fiction. I vowed to never cultivate a mean, sadistic nature present in these hard core care givers.

As I was thinking about the KARDEX, a stream of odd ball and memorable entries returned to my obtunded consciousness. Every student nurse remembers their very first patient. Mine happened to be a pleasant, young Hispanic man recovering from a heroin overdose. Prominently displayed on his index card was a very good suggestion: No heroin on discharge.

Downey VA could be a very dangerous place to work and assaults were an unfortunate occurrence. A night  nurse pulled from the medical side of the facility left an ominous warning taped to the front of the KARDEX: Unsafe to be in attendance here  at ant time. DO NOT ask me to cover this ward again. I heartily concurred but could not do much about my situation. Building 66 was my permanent assignment.

Folks addicted to drugs had a very difficult time in vintage hospitals and old school nurses seemed to delight in social engineering to make their stay as miserable as possible. The old "That'll learn ya" attitude on steroids. A frequent entry on a drug addicted patient's Kardex was: Known drug abuser-no pain meds of any kind.

Floor is slippery. Patient expectorating giant phlegm globs.  Enough said.

If patient is experiencing difficulty voiding, have him blow through a drinking straw. Along with running the sink, this trick really worked.

On the post-partum unit: Remind patient to pull inverted nipples out. if the delivery experience wasn't bad enough.

A patient, Dudley, that I cared for as a student nurse smelled of urine no matter how carefully I bathed him. A perusal of the KARDEX offered an unusual explanation of the pungent odor.  Remove patient's prosthetic leg  from the room on PM shift. He awakens at night and fills it with urine.

Have footwear at bedside for AM pulmonary function testing. We all knew what this entailed.  PFTs were conducted in the stairwell at the end of the hall. If a patient could ascend  2 flights of steps with a  resident encouraging him from behind, he was deemed an acceptable surgical risk. Just be careful not to slip on the giant pools of phlegm/mucous left behind on the steps.

Some patient families are prepared for just about any contingency. I remember well the family that brought a 3 piece suit to the hospital with a dying patient. The KARDEX notation:  Make sure the suit in the clean utility room goes with the undertaker when he comes for the body. Yikes!

KARDEXES were the hospital equivalent of a jungle telegraph and revealed information that you were afraid to ask about or never knew existed. I think rigid and permanent forms of medical record keeping, electronic or paper, can block nursing inventiveness that drive holistic care. The old KARDEX unleashed the nursing free spirit by delineating what really worked for the patient.


  1. Oh!!! How CAN nursing survive without our beloved Kardexes?!?! If I was admitting, I always tried to make mine a work of art (so to speak), and there was always that hidden back side where additional ~ ahem ~ info could be hidden... Such as "Family is real PITA"!!!

  2. Is there a place for nursing nuances in the modern electronic record keeping systems?

    1. Yes, there is. Heavy use of quotation marks removes all the mystery so there is no confusion. Pt states, "You are all a bunch of fucking idiots, I want my dilaudid right now or I'm calling my fucking lawyer to sue your asses, then I'm throwing this chair through the fucking window". I'm told a defense attorney would be reluctant to read that type of narrative in court. And when patient services reviews in response to the inevitable patient complaint, they can take a great deal of satisfaction in reading it back to the complainant

    2. Quotation marks are a great idea. If I was working as a nurse today (a scary thought indeed!) lots of my charting would be in quotes.

      In my final years of nursing. POMR (problem oriented medical record) advocated by Dr. Weed was in vogue. It was that good old SOAP format with the note starting of with a quote. I wonder if anyone is still using POMR.

  3. A delightfully written post OFRN that certainly brings back memories - and makes me feel positively prehistoric... Love the bit about the prosthetic limb! Jono above has a good point about nursing nuances being lost.. Sue.

  4. Thanks so much for all the comments. Jono, I have never worked with EMRs but you have a grand idea. Sometimes the nuances and subtleties of nursing notations offer the best approach to patient care if you can look beyond the dark humor.

    I overlooked one important component of vintage KARDEX notation: the do not tell list. Paternalistic physicians would not want to inform their patients of horrendomas, diseases that are terminal. The more grim the prognosis, the less likely the patient would be informed. When one of these patients aske their nurse an illness related question the stock reply was, "ask your doctor." That abdominal pain from metastatic ovarian cancer? "Oh...that's probably something you ate for lunch," was atypical old school physician response. Blame the pain on hospital food.

  5. This reminds me of how, when writing a criminal report, we would describe a knock-down, drag-out fight to handcuff an uncooperative individual as "the suspect was assisted to the ground for handcuffing".

    1. Thanks for commenting Officer Cynical. I betcha it's a different story today with body cams. Electronic doodads always make me long for the good old days.

  6. Someone at the hospital I work at, recently suggested bringing back the KARDEX. I've been a nurse for almost 30 years and love KARDEXs but the young nurses see no use for it. They are tech savy. I'm good at the computer but can also remember that it was much easier to jot something down then to log in and off a computer. I added up how much time I waste just getting to my patient's electronic chart and it's about an hour per shift. Just logging in and logging out. The KARDEX revival was shot down simply because it's ONE MORE THING to fill out. Charting has become such a lengthy, redundant ordeal. It also seems every department believes I have a "few more minutes" to fill out one more form in order to make their department's job easier while I'm drowning in virtual paperwork.

    1. There is something very comforting about information that does not rely on a computer to boot up. I liked the tactile sense of thumbing through a Kardex almost like strumming a tune on a fiddle. That reassuring clicking sound as the pages was nice too forming a background sound for peaceful meditation. Sure beats the clickity clack of a computer keyboard.