I witnessed my patient have "tremulous" legs for about three seconds. I had some serious doubts that it was an actual tremor; it happened when I pulled his blanket off his legs, and I thought at the time that his legs were shaking that little bit because he became cold. He acted concerned about it, but also said that this happens every once in a while. He asked that I document it so his primary doctor would know that it happened.
If I do remember correctly, I did document objectively, something like, "brief shaking noted in BLE when blanket removed, patient states this was involuntary; will continue to monitor" or something like that in my hourly assessment flowsheet when it had happened. I asked him to please let me know if it happened again, but he never said anything to me about another episode. During the 12 hr shift I took care of him, he was a bit needy and needed a lot of emotional reassurance, and struck me as the type of person who typically makes a mountain out of a molehill.
Imagine my surprise when I receive a email from our hospital patient advocate services office. The patient advocate told me that he had wanted to talk to someone in their office about me. Apparently, he was told by the nurses who later took care of him on the med/surg floor he transferred to that I never did "write a report" like he told me to.
In our charting at my hospital, nurses chart by exception within a documentation flowsheet and have the option of writing specific comments, which I had done. We write only two type of narrative notes: care plan notes , and significant event notes (any invasive procedures, CODES, blood transfusion reactions, seizures, etc. You know, ACTUAL significant events!)
He basically wants me to write a significant event note about his legs shaking for three seconds. I think it's inappropriate and a bit ridiculous to write a significant event note about that. I really do think my comment about it within my assessment flowsheet is adequate.
I plan on talking about this with my manager, but I would appreciate any feedback on what any of you would do in a situation like this. I've never had my documentation questioned before, and while I can understand this patient's concern, I'm a little angry that he's basically demanding and involving the patient advocate office over this, trying to get me to endorse something I don't feel 100% certain is a legitimate health issue. Am I being way off base here?
