question: can you chart on a pt. being rude? - Page 4Register Today!
- Feb 14 by mariebaileyDocument 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
- Feb 15 by redhead_NURSE98!Quote from woohObjective 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."
- Feb 15 by redhead_NURSE98!Quote from Twinmom06OMG. 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"? LOLwe 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...
- Feb 15 by Good Morning, GilI 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.