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)
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.
Specializes in Emergency Nursing Advanced Practice.
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"
Specializes in Emergency Nursing Advanced Practice.
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.
Specializes in ER, NICU, NSY and some other stuff.
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.
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.
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)
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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
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.
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?
Farting heads off? :chuckle Sorry, couldn't help it. I'm in a 4th grade mode. -Andrea
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.
I doubt a court, a judge, administration or a lawyer is going to take any sympathy on "gee those poor nurses, look at the jerks they have to take care of". The standard of nursing care remains the same, jerk or nice guy.
If it makes your coworker feel better thinking people actually care we take care of jerks, then let him/her have at it. :chuckle
papawjohn
435 Posts
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