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 say that she didn't understand... Read More

  1. 0
    I am a new Medical Assistant. This is invaluable information for me starting out in my healthcare career. I always want to be accurate and clear in charting information. Thank you!

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  2. 0
    This is great! I was precepting someone last night and we encountered this kind of situation. I had to document on it and so did she. I am going to print out this article and give it to her.
  3. 0
    Thank you so much for this! I just got home from an overnight during which I took care of many "inappropriate" patients. This is a good reminder and I love some of the examples you use.
  4. 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.
  5. 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.
  6. 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.
    ~miss_mercy_me likes this.
  7. 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!
    silverbat and JustMe54 like this.
  8. 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.
    ~miss_mercy_me likes this.
  9. 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!
    SHGR likes this.
  10. 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.

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