"Accurate" Charting of Profanity

[RNCENCCRNNREMTP]

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?

[suzanne4, RN]

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]

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]

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.

[elkpark]

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]

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]

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

Pt is a ......

[Tweety, BSN, RN]

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]

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?

[suzanne4, RN]

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]

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?

[blufoxtrot]

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.