"Accurate" Charting of Profanity

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Does anybody else in the ER/ED do this? If a patient is using foul language directed at staff (calling us names, every other word is F**K or Motherf****r, etc) I chart, in quotes, exactly what the patient is saying. I do this so that if later, the patient has a trumped up complaint then the chart reviewer has a good feel for the actions and behaviors of the patient.

Some in my nursing administration (imagine) frown on this saying it makes the chart look "bad". (Too much religious leadership in my hospital organization and way too much a**-kissing)

Anybody else do this?

[Ruby Vee, BSN]

If a patient is cursing at me all day long, I won't chart every outburst. but believe me some of the more colorful ones are in the chart -- if the patient causes problems down the road and a lawyer is going to be looking at the chart, I want it to be accurate.

[mcknis]

I always chart what the patient said, unless it isn't the key thing going on, such as the 80 year old man who has worked in the coal mine his whole life and the only words he knows include f***, d***, and s***. Some of these guys drop these words every other word, but if it clearly shows their anger at the time, then yes I write it, and place it in quotes. Religion has nothing to do with what a pt states. I am a born-again, Bible-believing, Christian and proud to say it, but even though these words are not included in my personal dictionary, does not mean that they do not exist and that others do not use them. I don't have to repeat them, but I do have to chart what the pt states.

[imanedrn]

I chart verbatim in quotations marks. That's what they're for, after all. Whether it looks "bad" or it's a model of prettiness, I want my chart to reflect the reality of the situation -- esp if I have to defend myself against a patient who verbally assaulted me.

[noah777]

I have attended two seminars on Legal Defense in Medical Documentation. I am not a nurse. I am a PTA meaning I must always follow through with what my supervisor tells me to do. Yesterday I had a patient that never wants to get out of bed. I educated him on my he was cleared by nursing to get up and sit in a chair for 30 minutes. He said nursing left him to suffer for three days (inaccurate) with a blocked catheter and how would that make someone feel? He wasnt over it yet. But his daughter was trying to cut his hair in bed and she was having a hard time reaching her dad. So I tried again to encourage him to get up to which he replied Goddamit, I'm too sick to sit up! Nobody ******* Believes me!

My supervisor read this and was very offended. She said I could get in trouble. She advised me twice (and I always have to do what I am instructed to do) never to write down exactly what a patient says if it is cursing, inappropriate, profane or vulgar language because it is unprofessional and offensive to who ever is reading it. I would think that sugarcoating something is not objective information. I was not trying to offend my supervisor. I was trying to show how much this patient did not want to get up because when I had written inappropriate language, the man is back on my schedule again the next day. Most importantly if I use terms such as inappropriate, abusive, cursing, to describe what he said, this can be SUBJECTIVE. What one person finds extremely offensive another might not... By writing down what he said I leave it up to the reader to decide if the man is using inappropriate language. Any ideas out there? Can I get in trouble for writing down a direct quote? That seems like even more reason to write it down. thx noah

[thelema13]

What they say goes directly in a quote, I shouldn't have to stand for that type of behaviour and abuse, and most of those types of pts end up complaining and the chart gets reviewed. No one has corrected menyet. BTW I work at a seventh-day adventist hospital. Uber Christian, with prayers being said over intercom and prayer cards and chaplain visits to every admitted pt.

[ninjago]

Noah:

"I would think that sugarcoating something is not objective information. I was not trying to offend my supervisor. I was trying to show how much this patient did not want to get up because when I had written inappropriate language, the man is back on my schedule again the next day. Most importantly if I use terms such as inappropriate, abusive, cursing, to describe what he said, this can be SUBJECTIVE. What one person finds extremely offensive another might not... By writing down what he said I leave it up to the reader to decide if the man is using inappropriate language."

Agree 100%. I always chart whatever pt says, profanity and all in quotes.

[DebanamRN, MSN, RN]

I also chart exactly what they say in quotes, because I am never gonna remember it if I go to court.

[RNFiona]

I quote them warmly and accurately ?

[psu_213, BSN, RN]

I know this is an old thread, but given the recent responses, I figured I would give my

I chart the exact words, in quotation marks, if they are being verbally abusive/threatening and/or I think they may complain about the situation. For example, if a pt says "oh f*** that hurts" when I am starting an IV, I won't chart it. On the other hand, I recently had a pt who unleashed a tirade on me when I would't give him a bus pass then expanded his thoughts when I would not give him a sandwich before he left. I charted in quoted word for word what he said. If he complained that I was not nice or unfair or whatever, whomever reviewed the chart from the hospital would be more aware who was in the wrong (they would still probably blame me, but I felt better about it).

One issue I have with "sugar coating" what they say (i.e. charting "the pt used multiple profanities and swore at the staff"): this is not going to be published in the local paper. If they raise a complaint, the proper folks in the hospital can see what an a** the pt is being. If no one ever looks at the chart again, then the profanity is lost forever.

Finally, if a person doesn't want those words in "their" chart, then they had the choice to not threaten someone with such profanity. If they chose to do it anyway, it's the pt's words in the chart, not mine.

[Merlyn]

I chart exactly. Word for word, I neither make the patient look bad or good.

[nurse2033, MSN, RN]

Quote the patient. It looks bad? Yeah, because it is bad that the patient is cursing you out. If someone asked me to censor my charting for a PG13 audience I would laugh at them.