Is there a proper way to chart what a patient/resident says?

[black_widow192]

I am a fairly new nurse, and I am working my first job. Is there a proper way to chart what a resident says? I was taught in school to ALWAYS ALWAYS chart exactly what a patient/resident says no matter what it is. Tonight when I got to work a co-worker yelled at me for putting his name in my nurses note because it made him look bad. The only reason his name was in my nurses notes was because the resident stated "so & so didn't give me my medicine all day, and he told the aides not to come in my room." This resident is very paranoid, always yelling at the staff, saying things like "i'm gonna F**K you up" & "it's my word against yours, i'm gonna have your license." Was I wrong to chart exactly what she said? Was I wrong to put his name in my notes?

[ccoache]

I have been a nurse for 5 years and the only time I have ever used another staff members name was if I had to notify a member of management of an incident that has happened. Never with a patient who was being accusatory of other staff at hat point address it with the staff member and then management should be notified to protect all of the direct care staff and no one should go into that room alone with that particular resident this is a learning experience

[trai1971]

I would chart something like "Pt. states he did not receive a.m. meds., administration of a.m. meds. was verified...", then go on to describe the other behavior. I don't put another staff members name in the chart unless they've helped me with a procedure, and I always tell them if I do. Hope this helps:)

[joanna73, BSN, RN]

Sometimes residents misinterpret events, and/or forget/ misinterpret/substitute staff names. Or fabricate events. To avoid conflict, I do not chart staff names, because the chart is a legal document. I would chart, "Resident states that an evening staff member did not administer colace." Or, "resident reports that evening staff member...insert here...Writer will mention same to staff." Something along those lines. I provide care for many dementia residents. What happened/ didn't happen may change minute to minute, as an example. You can never really be certain.

[proud nurse, BSN, RN]

I'm a real stickler for documentation. I wouldn't have put a co-workers name in my charting, and I also would be upset if someone named me for something that wasn't done per a patient. When I worked in LTC on nights, I frequently had residents tell me the PM nurse didn't give them their meds. First thing I did was check the MAR to see if the med was signed out. Then I'd go to the blister pack or narc drawer and check against that. If it was for an inhaler or eye gtts, using my best nursing judgment I might administer it since I really couldn't tell. If all else failed, I'd document like the other posters said.

I've had residents tell the next nurse I didn't give/do whatever. Perhaps they thought I had left for the day. The nurse will come to me and say "did you give so and so their med? They're saying they didn't get it." I will pay a visit to that resident, and in a non-confrontational and non-accusing way refresh their memory. I hate when people lie on me.

To the OP, what's done is done. If something goes to court, it wouldn't be difficult to find out who the nurse on duty was at that time.

[mariebailey, MSN, RN]

I'm a real stickler for documentation. I wouldn't have put a co-workers name in my charting, and I also would be upset if someone named me for something that wasn't done per a patient. When I worked in LTC on nights, I frequently had residents tell me the PM nurse didn't give them their meds. First thing I did was check the MAR to see if the med was signed out. Then I'd go to the blister pack or narc drawer and check against that. If it was for an inhaler or eye gtts, using my best nursing judgment I might administer it since I really couldn't tell. If all else failed, I'd document like the other posters said.

Good point. A little investigating & verifying before documenting is logical!

[jnb156]

I feel you have every right to include a residents name in your documentation. If he/she said something that he is worried about then maybe they need to be more careful what they say. If this resident is confrontational it should be reported to your unit director, and someone in charge needs to be aware of this residents unprofessional behavior. If you are uncomfortable with this, your facility should have a way to leave complaints anonymously. If he is yelling and using profanity with the other staff, who knows when this behavior will be directed or at the least witnessed by a patient or their family. Just documenting the resident said would be enough as well because they would be able to figure out who was there that night.