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Discussion

#$%^&&* and documentation

This came up recently at work . If there is a AO3 pt who is very verbally abusive etc do you document exact words in the chart? Some nurses insist on doing so, management says NOT to, if anything is to be documented they want vague terms but those words are subjective such as aggressive, foul language, cursing, etc and almost seem to question the need to document anything the pt says. . ..... I don't want to go into too much an explanation online about the exact scenario but there was a pretty big staff divide over it.

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    If pt makes a simple foul statement like "I hate your f*cking fat ass" No, I do not document the exact words.

    If pt makes a threatening statement like "I am going to rape your f*cking fat ass" then I document and call MD for a psych consult because he has now become "a danger to himself or others" and requires specific documentation for it to be addressed correctly.

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    What was the reason given by management to subjectively document, rather than judiciously document with objective quotes when a patient shows a pattern of behavior?

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    What was the reason given by management to subjectively document, rather than judiciously document with objective quotes when a patient shows a pattern of behavior?

    no clue, i think the manager thought it was probably not relevent enough to be part of the chart. I am not sure. I have seen people document things like, " pt stated, 'get the f%^& out of here' when I tried to obtain vital signs" etc I just put down "pt refused." etc.

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    • Expert

    I can see the nurses' point of view. Let's say that completely oriented patient continues refusing basic care (like VS), and the patient goes bad, but then recovers. The aggressive patient may be the litigious type, and when the medical record goes to court, the context of "pt refused" has no supporting objective documentation. Does one really think the plaintiff will admit to tx or monitoring refusal?

    I had a patient who was an ******* with a history of refusal and even AMA. However, he keeps coming to our ER and consenting to admission. One of the ancillary staff told me he refused basic monitoring. I went to talk to him, and as soon as I walked in--keep in mind I hadn't said anything yet--he said, "I didn't refuse!!!"

    Yeah, right buddy.

    ETA: On the other hand, maybe management is seeing it being used as an "out" or not as judiciously as it could be. Just using the objective quote does no good if there isn't also documentation on attempted patient education.

    Management needs to explain the "why" and fix the real issue they are trying to address, using nursing concerns as a basis for dealing with it. Sounds like a management/floor disconnect.

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    I agree with barbyann. Depends on what was said

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    Whenever I've had to document swearing patients, I've used asterisks for the swear words.

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