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 why her note was unacceptable. I asked Jane to read aloud the note in question:
"Patient was inappropriate."
"What's wrong with that?" she asked, explaining that this particular patient had been rude the day before, yelling that it took too long for Jane to retrieve her narcotic prescription. The patient had, apparently, shouted a few choice words at this nurse while exhibiting some threatening behaviors.
Jane's documentation, however, did not reflect that.
As nurses, we need to chart specifics, and we also need to be objective. This is straightforward when we are describing, say, a wound that can be measured with a ruler, or a patient's report of pain as "burning in nature rated at a '6' on a 1-10 scale." But when it comes to behaviors, things get a little more difficult. A patient's wrath can evoke a negative response within the nurse that makes it difficult for him or her to remain impartial. Also, nurses may lack the precise vocabulary to explain the event.
Jane told me that she had felt threatened by this patient, describing her as angry and inappropriate.
"Okay, Jane," I said, "what specifically did the patient do or say that made you think she was angry?"
"She started yelling. She was talking loud and fast."
"So you could chart that the patient's speech became louder and faster. What did she yell at you?"
Jane repeated some choice four-letter words that had been addressed to her.
"Great, I would have charted those verbatim. Use quotes. What about her stance? Did she get closer to you, point, stiffen up? What gestures did she use? Did she threaten you?"
Remember that the chart is a legal document and, as such, can be considered evidence. An accurate, unambiguous description of behavior, statements, stance, and gestures will stand on its own in a chart review. If you ever need to testify in court, the specific words will speak for themselves.
The same goes for what patients say over the phone if you are a telephonic nurse: chart specific words in quotes, a tone of voice, or change in tone if that occurs. If words are slurred, chart that.
Don't use subjective words such as agitated, upset, verbally abusive, aggressive, angry, or, as Jane did, inappropriate. These are ill-chosen because they are interpretations of behavior, not precise narrative; being subjective interpretations, they mean different things to different people. Instead, chart specific behavior, actions, and appearance. Some examples are:
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Pacing
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Clenching fists or jaw
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Reddening of the face
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Trembling of face or body
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Stiffening of body
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Sudden movements
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Changes in vocalizations such as voice becoming louder or faster
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Approaching or touching the writer or other staff
Use exact quotes whenever possible, including any obscene or threatening language that was used. One of our allnurses members, Meriwhen- an experienced psych nurse- is clear and unapologetic about this: "I've written out, in unedited and exquisite detail, the most profane things that patients have said...if they're addressing me and/or I hear them being verbally aggressive to others, they will get quoted verbatim. And I never asterisk/ampersand anything out, not even the really bad words.... As they were making threatening statements to us, I documented it all word for word" (Meriwhen, 2013).
After our discussion, Jane was able to compose the following thorough, specific, professional late entry note about the encounter:
Quote
"Patient stated 'It took you too darn long to bring me this prescription.' Patients voice became louder and faster. Patient stepped within 12 inches of this writer and pointed finger in face. 'Tell Dr. Smith that he's a terrible doctor! I'm never waiting this long again!' Patient declined offer to speak with clinic manager and left building without further incident."
May your documentation, likewise, always be descriptive, specific, and accurate, and may your patients always be cooperative.
