The other night, I bent over backwards caring for this frequent-flyer drug seeker, making doctor calls, making sure his NPO status was removed the instant his testing was complete, diverting lab personnel so his labs could be drawn immediately, etc., etc. Nice as could be. Never had him as a pt before, but have seen him around. I served compassion with a smile and had my game on. My other patients were awesome, it was probably the best night I've had in a long time.
So...next morning, the day nurse tells me the pt accused me of not giving him his prn percocet at 0600! States he thinks I pocketed them, but that he "didn't see me do it." Then he apparently spent the day telling dialysis staff and whoever else he encountered that I had stolen his percocet. He was also caught smoking in the bathroom, but he lied and said he wasn't.
Fast forward, I came back and was supposed to be his nurse again, but I refused and switched his room with nurse K for a different one. Unfortunately, Nurse K had an issue as well. He was holding his percocet in his fist and would not open it and take the pills. he told her he had already taken them. So she told him she did not see him take them, and to open his hand. He refused. Finally he opens his hand, and oila! Two percocet. So he took them.
So anyway, I've been an RN for a year (LPN for 5 years before that) and this has never happened to me. Not sure what I should do. Thoughts?
Documenting observable behavior in the moment is charting on behavior. Documenting hearsay after the fact is not.
The OP did not witness the behavior in question, but was told about it later by someone else. It would be inappropriate to go back into the medical record to document this behavior in retrospect.
However, "Nurse K" certainly could have documented the episodes that s/he was directly involved in, in an objective, unbiased manner. Nurse K could have additionally used the incident reporting system to document a behavioral incident.
In my facility, we document by exception, so a behavioral note on every single person, even if they are calm, cooperative, and answering questions appropriately is not necessary- unless this is relevant for some reason. However, any behavior that seems out of the norm should be noted, using the patient's own words when possible.
Anna Flaxis, BSN, RN
1 Article; 2,816 Posts
Documenting observable behavior in the moment is charting on behavior. Documenting hearsay after the fact is not.
The OP did not witness the behavior in question, but was told about it later by someone else. It would be inappropriate to go back into the medical record to document this behavior in retrospect.
However, "Nurse K" certainly could have documented the episodes that s/he was directly involved in, in an objective, unbiased manner. Nurse K could have additionally used the incident reporting system to document a behavioral incident.
In my facility, we document by exception, so a behavioral note on every single person, even if they are calm, cooperative, and answering questions appropriately is not necessary- unless this is relevant for some reason. However, any behavior that seems out of the norm should be noted, using the patient's own words when possible.