Charting disruptive patient behaviors: Are you objective? Charting disruptive patient behaviors: Are you objective? - pg.2 | allnurses

Charting disruptive patient behaviors: Are you objective? - page 2

One of my fellow nurses- let's call her Jane- was overheard complaining loudly this morning. She had received feedback from a physician that one of her chart notes was "unacceptable." She went on to... Read More

  1. Visit  texasmum profile page
    #13 0
    Very informative. I work med-surg but here lately we have had more and more patient's that I would loved to have charted as a "Royal PIA!" Rude, demanding, threatening, um, no.
  2. Visit  PTKChic profile page
    #14 0
    Thank you so much for this article. I am currently a CMA and was definitely undereducated when it comes to proper charting technique. I will keep an eye on what I write in my notes.
  3. Visit  amygarside profile page
    #15 1
    Sometimes, when I become too emotional that I can't write a good documentation I just pause moment, take deep breaths, and go back to charting again. It works with me.
  4. Visit  fiesty_red_head profile page
    #16 2
    Except when you work for a facility that the DON finds it inappropriate to quote the swear words. I don't know how many times I was threatened with a write up for quoting the exact words said. My point always was it is my documentation and license, so write me up then!
  5. Visit  Ruby Vee profile page
    #17 1
    Great article and great reminder. I'll admit that my charting of disruptive behaviors could use improvement. I'll never forget my manager calling me into her office and explaining that while charting "Patient confused to time, place and situation. Attempting to converse with Alaris pump, states 'That uppity bastard won't talk to me!'" is certainly descriptive, it probably is not that professional! Your examples were both.
  6. Visit  hotwaterbottle profile page
    #18 1
    I have worked in inpatient locked psych units with children, adolescents, and adults, so having to deal with this sort of charting was a daily occurence at my jobs. One of my pet peeves was cowowrkers charting "Pt. was whiny", or better yet, "Pt. was whinny". I saw that from more than one person!
  7. Visit  lovin profile page
    #19 0
    Excellent reminder. Clear, accurate charting is difficult and it is best to use exact quotes and to describe the situation precisely. Although, it is more time consuming than simply checking the box for agitated and irritable.

    Thank you.
  8. Visit  OneDuckyRN profile page
    #20 2
    I thought of this post as I took care of a patient who also happened to be in police custody. I have never needed to directly quote obscenities in charting before, but after having several shouted at me as I was explaining what would happen, I didn't even hesitate. Thanks for posting this, hey_suz!
  9. Visit  AJPV profile page
    #21 2
    I chart all the juicy details. Pt stated, "@!*! *%!" Pt then threw urinal holding approx 700mL of urine. Urinal struck wall approx 12 inches from my head and left urine splatter pattern on wall approx 3 feet in diameter. Pt then verbally compared my physical likeness to several species of livestock. Pt then threw overbed table through window." You get the idea...
  10. Visit  Ruby Vee profile page
    #22 0
    Quote from AJPV
    I chart all the juicy details. Pt stated, "@!*! *%!" Pt then threw urinal holding approx 700mL of urine. Urinal struck wall approx 12 inches from my head and left urine splatter pattern on wall approx 3 feet in diameter. Pt then verbally compared my physical likeness to several species of livestock. Pt then threw overbed table through window." You get the idea...
    I'll bet you write some entertaining notes!
  11. Visit  SHGR profile page
    #23 0
    Quote from AJPV
    I chart all the juicy details. Pt stated, "@!*! *%!" Pt then threw urinal holding approx 700mL of urine. Urinal struck wall approx 12 inches from my head and left urine splatter pattern on wall approx 3 feet in diameter. Pt then verbally compared my physical likeness to several species of livestock. Pt then threw overbed table through window." You get the idea...
    Yikes, I'm glad I don't work where you work!
  12. Visit  cjcsoon2bnp profile page
    #24 1
    Quote from Meriwhen
    Great article even without me in it

    Charting objectively is a challenge in psych because if you don't document specific behaviors, it can easily be construed as opinion and/or challenged by others. It can also be confusing because one person's idea of "inappropriate" behavior may be another person's idea of behavior that's isn't really too bad.

    What helps me is using "AEB" to explain why I've charted someone/something as I did. It's old school, but it works for me. There's always the possibility that someone may disagree with my assessment of a patient, but with "AEB" they can see what behaviors, quotes, observations, etc., that led me to my conclusion.
    I really like AEB and although I haven't used it in my documentation (post-nursing school) but I am seriously considering it when I write my next note.

    !Chris
  13. Visit  SHGR profile page
    #25 0
    Thanks for the positive feedback, everyone!

close