question: can you chart on a pt. being rude? - page 2
Is it just part of our job as a nurse to deal with rude behavior and the name calling or can i document on a pt being mean, grabbing my arm tight when yelling at me, accusing me or just mocking me?... Read More
Feb 13, '13You can describe the behaviors, but not assign labels.
Even words like "agitated," "aggressive," "combative," "resistive" are not adequate when charting. Write exactly what happened, using quotes whenever you can.
Also note what you did (again, describe exactly the actions you took, do not use vague words like "redirected" or "de-escalated") and then describe the pt's response.
"Pt became agitated and verbally aggressive. RN redirected, pt continued to escalate, becoming combative. Code Green called, pt given Zyprexa 5mg IM, Zyprexa effective."
That note has lots of very vague information. It is completely useless though, to anyone else on the treatment team. Why did the pt become agitated? What was he doing? What does verbally aggressive mean? What exactly did he say? How did staff respond? What does combative mean? What did he do? In response to the Zyprexa- how long did it take to have effect? What does effective mean? What are his behaviors 30 min after the injection? 60 min after?
The answers to those questions will be much more helpful to everyone on the treatment team. It can help prevent the situation from reoccurring.
It can help the physician decide if medication adjustments are needed.
Feb 13, '13Quote from Rhi007Haha at my ED we can fine people!!! One of the nursing staff, when he first started didn't speak great English and was told by a patient 'go back to where you came from' so he fined the patient $200
LOL how do you get them to pay up????
Im sure the majority of them don't have money- so this is kinda a moot point...
Feb 13, '13Quote from Rhi007Where do you work and how does this work????Haha at my ED we can fine people!!! One of the nursing staff, when he first started didn't speak great English and was told by a patient 'go back to where you came from' so he fined the patient $200
Feb 13, '13Quote from Nurse_I agree that facts, and only the facts, should be documented. I also like that someone mentioned to chart and intervention/evaluation. Suppose the patient grabs you, throws something at you, and cusses you out. A hour later another staff member goes in there and is physically harmed by the pt. It would not be a very good career move if you saw and charted dangerous behaviors but did not chart that you "dealt" with them.If the patient is rude, I'd chart the specifics of his behavior.
0800 "Patient states, "I don't want to see your face, get the **** out of my room." Pt. refused vital signs, slammed the door to hospital staff. Tried deescalating...
0845 Pt. paces the room, states he doesn't want to be in the hospital. Attempted to deescalate, patient slammed the door...
Document what the patient did, what you did to bridge the behavior and if it's a success or not.Last edit by Meriwhen on Feb 14, '13 : Reason: Quoted edited post
Feb 13, '13Quote from sarakjpI have written things like irritable, frustrated, resistant to care, combative, demanding, although I agree it's important to be as objective as possible. Quotes are great. & that patient seems like my worst nightmare. NO TOUCH!!!
Quotes are not only "great," they are the only thing you can write. "Pt could not hold his toothbrush to brush teeth, threw it on the floor and stated, 'I'll never be able to do this' in a loud voice. Pushed nurse's hands away when handed a new clean one. Stated, 'I want you to brush my teeth, the nurse yesterday did it, why are you making me? You do it, that's what you're paid for.' "
See, now you have established that he is irritable, frustrated, resistant to care, combative, and demanding in terms that anyone who reads that four years later (as I will when I review the chart) can visualize. Without that, it's your word against his. Word to the wise.
Feb 13, '13I almost always quote verbatim. Rude is subjective. If the pt gets physical, I chart specifics. Grabbed, pinched, squeezed, hit...
Feb 13, '13As previous posters have said, document objective findings only, nothing subjective. This also covers you, because if you have a patient who is extremely agitated and won't even let you get near them (we had a patient like that once...she even threw her lunch tray at a nurse when she walked through the door! ) and then they complain because you didn't do anything for them or they didn't get this med, this treatment, etc...your charting will cover you for that. And make sure to tell the doctor, too, that way they are aware and that also covers you. And document that the doctor was notified.
Feb 13, '13It's classed as discrimination and verbally abusive so the patient or patients family must pay the fine on the spot, a record of it goes in the patients file so other doctors know.
I'm at a university hospital and although events like that don't happen very often it keeps the patients in check.
I've also found many of the prisoners that come through are nicer than the public, even if they are shackled and have 4guards on them
Feb 13, '13Absolutely chart it. Like everybody else said, use objective language and quote whenever possible. Also document what you did to de-escalate the situation. If this patient ends up complaining about the "customer service" then you have yourself covered.
Feb 13, '13Objective notes are fun. I LOVE to quote patients and their families. Some of my most entertaining notes are quoting the families. People love my notes because I will quote the language.
And don't do *$%&# either. Did the patient say, "F-asterisk-dollar sign-percent-ampersand-pound"? No? Then don't write that they did!
Feb 13, '13I will use quotes from the patient if necessary. Like others have said, just state the FACTS - no speculation, especially when documenting these types of things.
Feb 13, '13I work in corrections and verbal abuse is a daily part of my job. That said yes I chart it in pateints chart with quotes. I have been lucky so far that it has not gotten physical thanks to our diligent correctional officers.
Feb 13, '13we had an OB patient over the summer that was making anti-Semitic slurs at one of the Jewish OB's as well as using really foul language...the OB's note started "in 38 years of my practice this is quite frankly the worst patient I've ever dealt with" - while it may not be the most PC way to chart we had a few good snickers...