"Accurate" Charting of Profanity

Goes word for word in the charts I touch. It happens it gets in the record. I could care less if a chart looks good? I want it to be accurate.

renerian

Ditto- what the patient says if its pertinent gets put in the chart- be it profane or otherwise. My response to management is that I am not going to fraudulently document or alter it because they "don't like it" . Sometimes the truth hurts.

I do not typically bother charting the bad words used; rather I sum it up with a statement like pt. verbally assaultive or pt yelling profanities at staff. IMHO that gives an adequate description that the pt's behavior was inappropriate.

Yeah, sometimes I chart profanities even when they didn't use them.

Pt is a ......

If it's a necessary part of the assessment and treatment of the patient, yes I quote word for word. Do I chart everytime a patient curses. No. I might chart "patient is very angry about.........and using profanity." the assessment being they are angry,with the curse words not being relavent.

RNCENCCRNNREMTP said:

Does anybody else in the ER/ED do this? If a patient is using foul language directed at staff (calling us names, every other word is F**K or Motherf****r, etc) I chart, in quotes, exactly what the patient is saying. I do this so that if later, the patient has a trumped up complaint then the chart reviewer has a good feel for the actions and behaviors of the patient.

Some in my nursing administration (imagine) frown on this saying it makes the chart look "bad". (Too much religious leadership in my hospital organization and way too much a**-kissing)

Anybody else do this?

I do the same thing, just put quotation marks around the word. Your just quoting what they said. It is not like it is against the law, freedom of speech right (on your part)? and your simply writting what they said What do they want you to write? "patient called me the 'f-word' and then told me to kiss his bottom but used the not nice verson of it?" I don't get what religion has to do with this, what are they saying is wrong with what you are doing?

I chart word for word. If you don't like it welcome to my world in the ER. That is the way it is in the ER. We don't like being called that either. That's why if it goes to court. I want the judge, lawyer and pt's mother to know exactly what he or she said.

Hey Y'all

The chart you're making is going to be a record of the entire process of dealing with the Pt's condition and behavior. Hypothetically, assume the Pt is an OD, has had NARCAN and now wishes to go score more drugs and resume his chosen state of consciousness--but finds himself in committment (which we in FLA call 'Baker Acted'). He ends up in restraints and etc (which most of us can write the script for).

The profanity, threats, etc are material to what we have to do as the stupid drama unfolds. Leaving out the profanity and such leaves the sequel events unexplained--IMHO.

I chart enough to make it clear that a reasonable person with our responsibilities MUST have done what I did.

But then I always imagine that I'm reading my Nurse'sNotes to a jury, or that they're going to be read by a Attorney who will decide whether or not to sue me based on what I write.

PapawJohn