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

You can certainly chart on a patient's unbecoming behavior. However, it is recommended you do it in an objective manner that states the facts and leaves your personal opinions at the door.

"Patient grips this writer's arm and yells, 'All of you nurses are stupid witches!'" sounds more objective and factual than "Patient is mean, rude, and mocks this writer."

I 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!!!

If you are gonna write it, I agree it needs to be in a "patient with increased agitation" as opposed to subjective information--and be sure that you tell the MD, and then you are able to either get a prn for agitation, or "patient with increased agitation, MD aware, no new orders (or prn med ordered)" Then you can follow up as well about if the med worked or not.

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.

You could write " pt became physically and verbally aggressive".

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

To be honest, even that could be considered vague or too subjective. What you consider "verbally agressive" and what someone else does may be two different things. Idealy, you should just chart concrete facts. Chart exactly what he *said* and exactly what he *did* and let the facts speak for themselves.....

With that said, I've charted phrases along the lines of "resident became verbally abusive" more than once myself. In a perfect world we'd all have time to chart perfectly....

We have sections for behavior charting. This would definitely be charted and monitored.

I try to document this clearly as well. I often quote things said and if there is any physical contact I make sure to document this as well.