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

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. by   nurse.anni
    Sorry to sound stupid, I've never heard of AEB before - could someone explain if it doesnt take too long? Thanks
  2. by   LadyFree28
    AEB= As Evidenced By= supporting assessment and data collection; objective observation by the nurse.
  3. by   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.
  4. by   SHGR
    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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