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"Accurate" Charting of Profanity

Specializes in Emergency Nursing Advanced Practice. Has 30 years experience.

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?

What do they want you to do? If you are quoting the patient, which you should be doing, since it is your license and not theirs, do they want you to change the words? It would not stand in a court of law. Nor isit beneficial to just say that they were "swearing" at the staff. Perhaps someone from risk manangement or a lawyer should come in and have a talk with them.

renerian, BSN, RN

Specializes in MS Home Health.

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

rjflyn, ASN, RN

Specializes in Emergency. Has 23 years experience.

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've always (psych nurse for 20 years, so I've heard more than my share) charted exactly what the client said (as best I could remember by the time I finally got to sit down and chart 🙂 ), or, at least, examples of exactly what the client said (if it was a very long outburst ...). I use "f---, d---, s---, m-----f-----," etc., rather than actually writing out the actual words in the chart. Anyone reviewing the chart can decipher what it means ...

PMHNP10

Has 6 years experience.

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.

Happy-ER-RN, RN

Specializes in Emergency.

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

Pt is a ......

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

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.

VivaLasViejas, ASN, RN

Specializes in LTC, assisted living, med-surg, psych. Has 20 years experience.

I've been known to document profanity/obscenities by using abbreviations and quotation marks, such as "Pt waved gun at staff and threatened to 'blow your f---ing heads off'". That way there is no mistaking the patient's intent or the seriousness of the situation, without actually spelling out the words (which anyone with a 4th-grade literacy level can figure out). I'll admit I've never had such documentation challenged in a court of law, though; maybe someone with legal experience can help us out here?

psychrn03 said:
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.

You are then no longer being objective, but subjective.

HeartsOpenWide, RN

Specializes in Ante-Intra-Postpartum, Post Gyne.

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

RNCENCCRNNREMTP

Specializes in Emergency Nursing Advanced Practice. Has 30 years experience.

Looks like I touched a nerve, good.

I recently got complimented by a co-worker who said "We should all chart stuff like this when it happens, then they will see what jerks we have to care for"

My charting practice continues.

RNCENCCRNNREMTP

Specializes in Emergency Nursing Advanced Practice. Has 30 years experience.

HeartsOpenWide said:
I don't get what religion has to do with this, what are they saying is wrong with what you are doing?

I mentioned religion as questions of my charting practice (for over 20 years) were not raised until my hospital was taken over by a religious based hospital group. Will not name names for job security.

babynurselsa, RN

Specializes in ER, NICU, NSY and some other stuff. Has 12 years experience.

I have always used direct quotes. I think that charting pt verbally abusive is just not descriptive enough. I patient threatens to blow off my F******* head, then I want it clearly stated. If you simply chart verbally abusive they may come back and try to say they made a much milder statement. Otherwise after the fact it is simply their word against yours. You know the old saying if it isn't charted it wasn't done. I think it goes both ways.

suzanne4 said:
You are then no longer being objective, but subjective.

I agree. Whatever they say (in quotation marks) and whatever they do is exactly what I write in my documentation. When I was in school my instructors used to draw red lines through my concept maps and care plans whenever I wrote anything other than the patient's exact words and actions. One instructor in particular was extremely fussy about what is documented and how it should be documented. According to her, I should document exactly what I hear, what I see, and what I did about it. She insisted that anything more or less could mean trouble for me if a lawsuit comes up somewhere down the line.

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?

Chart them and do it exactly as they say them.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

I have been an ED nurse and critical RN for as long as I can remember. First It's your liscence not theirs. If you end up restraining them you are the one not them who can be charged with unlawful restraint and kidnapping!! Trust me the administration prefers that everything is pretty but it is not a pretty world out there. An estimated figure is that at least 89% of the patiets to the Ed have SOME etoh involved otherwise they would not have done whatever they did that was stupid! Of that percentage especially after 2300 are intoxicated or as in MA they are called COCKED! And the "F" word is their favorite. Of that percentage is the neglected psych population that use etoh to self medicate. So yes IF IT IS NOT DOCUMENTED IT DID NOT HAPPEN!!!! And in a court of law trust me The big hospital will attempt to let the little man (the RN) take the fall so yes reguardless if it sensitive to their holy ears tell them not to read the chart!!!! ED violence it one of the major health problems we ED staff face!! It is a criminal act to attack an EMT PARAMEDIC FIREFIGHTER OR POLICE but as nurses it's okay? I don't think so......DOCUMENT DOCUMENT DOCUMENT.!!!! In MA there is legistration before the Senate as we speak to make it manditory for hospital to report and defene Nurses that have been attacked It will also make it a felony!!! Talk to the ENA :angryfire xoxo lost in boston

chadash

Specializes in Nursing assistant.

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 am religious, but I agree with you. You need to chart exactly and factually. Stick to your guns, dag nabbit! You can quote me.

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