Charting disruptive patient behaviors: Are you objective? - page 3

by SHGR 14,293 Views | 29 Comments

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


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    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!
    MsLindaW and SHGR like this.
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    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...
    LadyFree28 and SHGR like this.
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    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!
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    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!
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    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
    SHGR likes this.
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    Thanks for the positive feedback, everyone!
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    Sorry to sound stupid, I've never heard of AEB before - could someone explain if it doesnt take too long? Thanks
    MsLindaW likes this.
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    AEB= As Evidenced By= supporting assessment and data collection; objective observation by the nurse.
    nurse.anni and MsLindaW like this.
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    I was taught not to chart something that implies a diagnosis of which I made. Nurses don't diagnose. I would not chart for example , "pt is having a psychotic episode". I would chart, " pt appears agitated as evidenced by cursing, shouting and attempting to strike this nurse". Then, it is up to the doctor to diagnose the etiology of the patients behavior. An attorney would tear a sentence like, " pt is behaving inappropriately " apart. They might ask, " is this your diagnosis"? How did you determine that this patients behavior is inappropriate? What is your educational background? I have had to go before a dozen or so lawyers in a huge board room three times with lawyers picking my charting apart line by line, word by word, and even questioned where the commas and periods were placed. This is a horrible situation to find yourself and your charting in.
    MsLindaW likes this.
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    Quote from marable
    I was taught not to chart something that implies a diagnosis of which I made. Nurses don't diagnose. I would not chart for example , "pt is having a psychotic episode". I would chart, " pt appears agitated as evidenced by cursing, shouting and attempting to strike this nurse". Then, it is up to the doctor to diagnose the etiology of the patients behavior. An attorney would tear a sentence like, " pt is behaving inappropriately " apart. They might ask, " is this your diagnosis"? How did you determine that this patients behavior is inappropriate? What is your educational background? I have had to go before a dozen or so lawyers in a huge board room three times with lawyers picking my charting apart line by line, word by word, and even questioned where the commas and periods were placed. This is a horrible situation to find yourself and your charting in.
    This sounds like my worst nightmare. I always try to chart as if I would have to defend it five years from now.


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