Quote from studentpn73
Just learning proper charting at the moment so please correct me if Im wrong!!
From my understanding we wouldn't use "non-compliant" in describing a clients behaviour would we?
Wouldnt we as nurses use something more along the lines of "Client stated "I want to be left alone" when writer went to help with ADL" so that when Sally Jones reads her charts, or if Sally's charts are ever used in Court, then there is nothing insulting to her character?
Again please please correct me if I am wrong...just a student sooo
Example: "Patient refusing to stay in bed. Non-compliant with fall risk safety protocols. Aware of risks of falling (including, but not limited to, breaking bones, strokes, bruises and pain), however patient states "You ****** cannot tell me what I can and cannot do." Patient informed about need to stay in bed, important of central line catheters, risk of them being pulled out and potential complications of this. Aware of need to use call light before getting up and waiting for staff, need to wear o2 when ambulating, non-skid footwear, IV lines that cannot be pulled. Bed is in low and locked position. Clear path to the bathroom in case pt continues to be non-compliant with fall risk safety and night light remains on. Reinforced that pt is not to attempt to ambulate without RN and without the use of a walker for stabilization. Addressing bathroom, hydration and comfort needs q1h, all personal items, call light, tv remote are within reach."
I chart very directly - I have had patients that when to DHS about issues with their hospital stays and I have had to sit down as one of their caregivers before to the board. I've been told directly by them and risk management that my charting is what has saved me from other issues that other nurses had with these particular cases.
I look at the patient as a whole, chart a full head to toe assessment, chart behaviors and I also chart interactions with the patient. I note when I did teaching and how the patient responds, I note if they or their visitors are appropriate with each other and the healthcare environment and when someone is choosing to be UNsafe - I chart the hell out of it!! Because its THOSE patients that come back and try to sue the hospital or the nursing staff because they fell, etc... I also make a point to chart QUOTES. If it is brought before a judge a note of "educated on fall risk behaviors and hospital policies but continues to get up.", and then you go to court and the patient says "I didn't really understand, I thought it was OK for me to go to the bathroom..." The judge will also look at how the patient was behaving. Name calling, cursing, aggression, etc... makes the patients mind-set at the time quite clear.
It can make charting take a while sometimes, but once you develop a habit, its really not bad and considering I have spoken to DHS *twice* AND I have talked to risk management about patients who come and try to sue for things - its certainly worth the extra 10 minutes to chart the details.
I probably would not chart like this in school, because of your nursing instructors and such - but I certainly do it while I work.