Doctor upset by charting

[LalaRN9000]

I work in mental health and sometimes distraught parents have unreasonable demands and expectations. Obviously this isn't a surprise when you're a nurse but I am just curious what other nurses would do in this situation.

My co-worker was talking to a parent who was pretty upset and she charted what the mom was saying. This included the parent saying that the doctor "must smoking something." The doctor ended up coming down to talk to her. He demanded that she take that statement out but the note was final. He told her to never chart things like that. It must have gotten heated because later she came out of his office in tears. Telling someone not to chart something seems pretty ridiculous. I am not really sure why the doctor acted that way, he is usually a pretty chill guy.

So would you document verbatim? I would.

[caliotter3]

If the doctor doesn't like what they said, maybe he should take some action, such as speaking to the parent about their dissatisfaction, instead of castigating a nurse for doing her job.

[Here.I.Stand, BSN, RN]

I'm picturing a courtroom and subpoenaed notes.

Would any of us appreciate the "smoking something" accusation refer to us...in ANY context? I don't know that I would trust every single tort lawyer to keep everything in its proper context. I have a feeling that's why this MD didn't appreciate seeing that statement about himself on a pt's record -- a legal document.

[Been there,done that, ASN, RN]

I always direct quote. I've had quite a few profanity-laced direct quotes in my charting. It's what happened. I had a post-op patient who was nwb to one foot. Patient was not having that. The doctor who operated is notorious for having RNs' butts for whatever reason. So when the patient told me I should shut my big fat mouth and the stupid bastard doctor could f himself, all while beating that post-op foot on the floor, you bet your butt I quoted that.

I think quotations are our friends in those situations. There's no "reading into" behaviours, they're factual happenings.

Wish I could have been a fly on the wall! :) Good job.

[PeakRN]

I have no problem directly quoting patients or family members statements, especially when they are affecting the care that we are giving. For example, when a patient tries to sue us or write a complaint because we restrained them it isn't going to hurt that you had already documented their non-compliance with the treatment plan in addition to what conditions caused them to be restrained. You want to keep it professional, but that doesn't mean you can't chart things that are uncomfortable.

[Axgrinder]

Maybe he was indeed smoking something and felt guilty? Maybe he had fight with his spouse, child, or lover. You just never know with people - doctors included.

If it's in quotes it is what was said. I do it a lot - complete with expletives, slang and vulgar innuendos. It gives a snapshot of the quoted's state of mind.

[Ambersmom, BSN, RN]

I always chart verbatim, especially in situations where someone is upset, the discussion is heated, or the person is stating I'm going to sue you or call a lawyer. I make a point to always make it clear who was saying what so, ie, patient's mother stated "blah blah blah" and to use quotation marks. I always do this because God forbid if I ever wind up in court, it will give me a refresher and be clear as to exactly who was saying what.

I wonder if perhaps your coworkers charting might not have been clear as to who made what comment, otherwise I think the good doctor doth protest to much.

[JKL33]

I should let this go, but to the last two posters (and others with similar thoughts) -

Yes, of course when approprite we chart verbatim things that patients say. Using quotes. Etc.

It becomes a question when the speaker's intent is not made clear by the quoted words. This is especially true when the quote could appear to literally accuse someone else of something or question their capabilities with no supporting context.

For instance, if I were to say that "Joe Blow can't read," would that mean that I'm being sarcastic about someone's reading comprehension, or that s/he actually cannot read? It's any future reader's guess - and under the circumstances of the OP, that is not an appropriate thing to chart in a medical and legal record.

[Libby1987]

MD progress notes: Patient unhappy with the nursing care, stated "that nurse stupid ***** never comes in the room". Meanwhile in other news, VSS..

It's a direct quote but pretty inflammatory.

I would have documented something more along the lines of, Patient's mother repeatedly verbally critical of attending MD, referred to charge nurse..

[AutumnApple]

In the doctor's defense, there are ways to say things without saying them. You don't have to quote everything directly. We're intelligent enough to know when to practice "as if the lawyers are looking over your shoulder" vs. just saying what needs said.

Judging by the details we're given, I can't help but wonder if something to the effect of "Family member expressed displeasure with specific members of the care team, furthered that they did not agree with all decisions." Of course don't just leave it at that. Follow up, direct the family member to someone up the latter who can moderate the complaints. And say you did so in your documentation: "Family member advised to make (manager, whoever you direct them to) aware of concerns. Advice well received (or not)."

Beyond that, the doctor trying to litigate what can and can not be in documentation is the low brow approach to solving the problem. They honestly don't have a say in it so, its wasted time trying to enforce your opinions on it. That could be brought up to your ethics committee. And I'd advise your friend not to give him an audience next time they approach them with this idea that they do have a say in it. Walk away, don't bother entertaining the very false notion . It's that simple.

On a side note: I don't advise documenting things like that verbatim because it most certainly can be turned around and used against you. You see, the powers that be will be more concerned with "Why was that family member so comfortable saying such things to you?" than they are with what was said. In short, if things get out of hand, they'll accuse you of egging on the strong statements. Very likely the doctor thought exactly this, hence the inappropriate reaction to it. He said "Don't document that." He meant "Don't encourage patients to make wild accusations against me." Just my two cents.

[hppygr8ful, ASN, RN, EMT-I]

Anyone who has worked adolescent or child psych knows that parents can be and often are a huge contributing factor to their child's mental illness. Since this was a comment from the parent and not the patient I most likely would not have quoted it. I would have put something to the effect that the parent was unhappy with the patient's progress and expressed distrust in the physician's method. I would also have let the physician and treatment team including the house supervisor know that we had an unhappy parent on our hands. In my facility every patient has a family session before discharge. While I chart carefully and accurately (Including direct quotes when relevant) I am always mindful of what my charting might reflect if litigation occurs. We also have Patient dissatisfaction forms that are not part of the legal record for patients and families to complain about their care. I mean I would not chart if a patient complained that their ice water was not cold enough!

Hppy

[JKL33]

So here's another real-life example to make my point. This was a rousing round of the game "Triangulation." Which I suspect also came into play in the OP as well.

One time I answered an "in pain" call light for the patient of a co-worker. Coworker had administered pain medication w/in the past 5-10 minutes.

Pt states to me, "I don't think that [pejorative] nurse gave me anything."

I inquired further. "Can you explain a bit more?"

>"[s/he] came in here with the pain medication and [s/he] put something in my IV but I'm still in pain."

"What do you think [s/he] put in your IV? Like, water or something?"

>"I don't know but I'm still in pain..."

"Okay, well, this is a very serious accusation you're making if you're not able to give any more details, so I will inform the Administrator in charge of the hospital so that we can take your report and deal with this."

>".....Well.....I mean.....I know [s/he] gave it to me but it wore off already...."

Yeah. That's what I thought.

****

Some of you are arguing that I could've made a legitimate quote in the chart: Pt reports continuing 20/10 pain and states, "I don't think that [fat/ugly/old/] nurse gave me anything."

Baloney.

[Susie2310]

Charting patient/family member comments that are not really central to the patient's care or to the patient's recovery can result in problems. We all make comments as patients/family members; we say things like: "I wish . . ." and "I think . . ." but I don't think we'd expect to find our more mundane types of comments charted on our permanent records. It brings up the question of the intention of the recorder; why are they scrutinizing and documenting selected everyday behaviors of ours.

I recently received some medical records for myself from a specialist MD visit, and the physician definitely didn't document my mundane comments or make a comment about my apparent mental state. He/she did clearly and thoroughly document their objective assessment and my statement of how much pain I was experiencing, and the treatment plan.