How do you chart verbal aggression by a client?

[RxOnly]

I participated in another thread and some of my advice to another nurse here was to document that the client was "verbally aggressive" among other things (the client had reamed her a new one, unprovoked). Other posters seemed to disagree with that and said that they write down word-for-word what a client says in their chart.

I'm definitely going to check with my nurse manager and ask her what is appropriate charting for my facility (as we encounter this behavior from our clients quite a bit). However, I'm just wondering what other nurses chart when they run into these situations.

Say, when you went into his room to give meds, Mr. Smith says "$%^! you and this whole &*!%%$ place, you are a &^%$#@ piece of &%*$!" Fill in the blanks with whatever words you like :) ...would you put curse-words in the chart, or write that he was "Verbally aggressive", etc. I guess I just feel funny as a professional writing the F-word in a client's chart... but if that's what my manager wants me to do, I certainly will!

How do you nurses chart these things??

[vald96]

definitely we are talking behavior problem? i will document exact words for words pleasant or unpleasant,it will be my documentation,difinitely i can remember these words in 5 years....not anybody else...my advice is review the regulation on proper documentation...protect your client and yourself..

[tyvin, BSN, RN]

Correct charting procedure is to quote the patient word for word in quotes. That way there is no misunderstanding. As has been said just putting verbally aggressive leaves it up for interpretation.

[Batman25]

I do the same as many others. Quote it word for word. That's proper documentation procedure.

[rngolfer53]

OP, it's not really you putting the offending words into the chart. You're simply the messenger. It's quite rare to have that where I work, but when it does happen, I quote word for word.

Using a phrase such as "verbally aggressive" leaves you open to having to defend your interpretation of just what constitutes verbal aggression.

[RescueNinja]

I chart word for word too, but generally I do "bleep" the profanity (i.e. "s--t" "b---h" "f--k" etc). You'd have to be living under a pretty big rock not to know what those mean these days...

[BabyLady, BSN, RN]

You cannot chart "verbally aggressive" because that is a judgment call.

You can chart what they say...if they use foul language, then write it down. They said it, you didn't.

If any of your charting starts off with the words, "I think, it seems, I feel"...then you are making an interpretation/opinion....which is not supposed to be charted...only what you see and hear.

[nightengalegoddess]

I have charted these situations word for word. I work in a catholic facility and yet I am still interested in defending my license if it ever comes up. There may be specific threats coming from the patients' mouths; and if the patients' were ever to somehow retaliate against the hospital, I would like it to be known what their words actually exposed about their characters. Just like many here have said, the patients' words....not yours.