question: can you chart on a pt. being rude? - page 3

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

  1. Visit  sandyfeet profile page
    1
    Quote from wooh
    Objective notes are fun. I LOVE to quote patients and their families. Some of my most entertaining notes are quoting the families.
    I feel the same way! Nurse SandyFeet, gettin' paid to swear.
    wooh likes this.
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  3. Visit  JZ_RN profile page
    1
    I document in quotation marks "patient words" and I also document patient behaviors. You don't need to say, the patient was rude and yelled at me and smacked me, I just write, patient began to raise his voice, saying "patient words" and then struck me in my left arm. If I have an injury like a bruise or something, document and file charges, take a picture of the wound, measure, etc.
    anotherone likes this.
  4. Visit  Meriwhen profile page
    3
    Quote from wooh
    Objective 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!
    Agreed. I've written out, in unedited and exquisite detail, the most profane things that patients have said. If the patient is not directing the verbal aggression at me or anyone in general, I'll leave the specifics out and say something like "patient swearing to himself in his room." However, if they're addressing me and/or I hear them being verbally aggressive to others, they will get quoted verbatim. And I never asterisk/ampersand anything out, not even the really bad words.

    Once, one of my notes read like a Quentin Tarrantino script. This particular patient was a 5150 that hated EVERYONE regardless of gender, race, ethnicity--including those of their own race/gender--and didn't hesitate to tell us all about it. As they were making threatening statements to us, I documented it all word for word.
    Jdoyle, greenbeanio, and wooh like this.
  5. Visit  SaoirseRN profile page
    1
    Quotes are my best charting friend, because as others have said, what is considered "verbally agressive/abusive" to me may not mean the same thing to others, but "Get the **** away from me, you stupid ****, or you'll be sorry" speaks for itself. I write it out verbatim, all the words the patient said. They said it, so I'll chart it.

    Also, others have said this as well, but chart how they appeared to you, which will often let the reader "see" the patient's state. Pacing, clenched fists, flushed face, clenching jaw when speaking, raising voice, throwing or pushing things, grunting, kicking, pulling at their own fingers, smacking/hitting/punching others, those kinds of actions are very indicative of the patient's emotional state. With described actions alongside direct quotes, it isn't so important to apply a word to the patient's state (agitated, upset, angry). Somebody reading the charting can interpret those actions and words as you did and see why the subsequent interventions (calling doctor, calling staff assist, orders for restraints or security, etc) were warranted.
    greenbeanio likes this.
  6. Visit  wooh profile page
    0
    Quote from Meriwhen
    Once, one of my notes read like a Quentin Tarrantino script.
    Nice!
  7. Visit  tewdles profile page
    3
    Describe the behavior rather than "diagnosing" it...
    rn/writer, Meriwhen, and psu_213 like this.
  8. Visit  mariebailey profile page
    1
    Document objectively and accurately, stating facts and avoiding assumptions. Avoid subjectively referencing a patient's behavior, such as calling him or her "frustrated". Instead, document what the patient states in quotes, regardless of how vulgar it is. If the patient grabbed you, I hope there was a documented intervention to address it so an even worse physical occurrence doesn't take place with someone else later. This CNE helped me with my charting: Document It Right: A Nurse's Guide to Charting | 60076 > Continuing Education Unit at Nurse.com
    Meriwhen likes this.
  9. Visit  redhead_NURSE98! profile page
    0
    Quote from wooh
    Objective 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!

    I usually stick one * in there. I don't want to repeat "sand n-----" in my note even though that's exactly what the pt said. (about his doctor who was from the Philippines, lmao) "Sorry sir, wrong ethnic slur."
  10. Visit  redhead_NURSE98! profile page
    0
    Quote from Twinmom06
    we 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...
    OMG. I walk out on this stuff and tell them I'll come back when they've calmed down. Are you allowed to walk out and say "Have the baby yourself"? LOL
  11. Visit  Good Morning, Gil profile page
    0
    I do document when these things happen, but I make sure it's objective. I never say, "patient was rude" even if they were because that implies that I'm somehow offended by this behavior, when in fact, I am not. It's just part of the job.

    But, I just explain what they do. If patient cursed at me, but then ended up quitting and falling asleep, I would say, "patient being verbally aggressive, demonstrating signs of alcohol withdrawal, including restlessness, increased BP. MD notified, ETOH withdrawal protocol started, 2 mg IV ativan administered, effective, patient calm, asleep in bed." Since this is usually the cause. If family happens to be there, then they can usually verify the drinking (if not in denial themselves). Or, sometimes the patient will tell you when asked "how much do you drink?" They'll say a pint a day. This all gets documented in a concise nursing note on the computer.


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