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? These a various pt by the way all elderly men....
Document what you see, hear and feel (not emotions but things like getting hit or scratched)--not what you think it means. Not, "Patient became rude and hostile," but, "Patient threw wash cloth, grabbed this writer's arm, and used vulgar language." This takes your judgment out of the picture and allows the facts to speak for themselves.
If you're going to be giving this patient for something for anxiety/agitation, it's much better to have an objective record of their behavior than your personal conclusion, which could make it look as if you medicated them because you were upset.
Last edit by rn/writer on Feb 16, '13
I'd chart something like that under psychological/behavioral. It's not about being petty or trying to "get back" at a patient for offending the staff. Charting on behavior/psychological/pt's affect has a legitimate place in your assessment.
And yes, I definitely chart it with lots of direct quotes and objective observations. It not only helps to create a baseline for the patient, but it can track increasing aggitation, long and short-term psych issues, how patients are coping with their diagnosis/hospitalization/treatment course and it also warns your fellow staff: docs, nurses, PT/OT, techs--everyone who has to venture bedside.
Last edit by SoldierNurse22 on Feb 13, '13
Feb 13, '13
by Nurse_, BSN, RN
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: TOS: removed profanity