I'm a LPN, RN student. I am in charge of approx 6 care aids (HCA) per shift. All are very good however not fully educated in dementia which seems to be the case everywhere (a whole other topic).
With dementia it is common for residents to accuse care staff/nurses of various type things. "Stold my towel, washed my back too hard". Etc
Although we ensure residents are not being abused, it is known that often times these things are just part of dementia and no one should take this personally. Except... If you are a care aid in this facility.
I feel it is important to chart these types of incidents to ensure we are doing our due diligence to ensure our residents are safe and keep a documented record. Well, some HCA's take issue with this because they think it makes them "look bad". No matter how many times I tell them it is just fact charting and does not suggest anything bad about the individual HCA.
Well, they report this to the nursing lead and I get talked to about this!
I do not understand why these HCA's who have been working for up to 20 plus years do not understand this?
Not to mention, I was talked to regarding communicating a PRN order. Which the order said that this medication can be given up to 10 x a day. The HCA's pass meds where I work. I guess one of them didn't like how this "sounded" and reported to the nursing lead. Yes. Talked to about this as well.
Another issue, I was told not to use quotes " " when charting what a resident said because it looks like mocking the person's words.
So, what I took away from my talk with the lead was, do not chart or make sure you word your charting so that the info does not make the HCA feel bad (eventhough no names are used), when communicating orders to HCA's make sure you say it in a way that the HCA's will feel comfortable with the how the order sounds. Oh and do not use quotations to to chart what the resident said to separate it from my narration because it mocks what the tenant said.
What?? If a resident says something in regards to care received then I feel its my duty to record this and the HCA's should know this and not take it personally.
If a Dr order says up to 10 a day (of course within medication administration standards/practices) then they can have 10 a day. How the individual feels about how it "sounds" is irrelevant. Not to mention if the resident needs this 10 times a day then they should be permitted to have it because its what the Dr orders are. It's not up to the HCA's to pass judgment on a Dr order.
And I also feel I need to document my observations which are objective, to separate the residents words that are subjective by use of quotations.
Am I out of it here and has everything I've learned not the right way?
Specializes in Psychiatry, Community, Nurse Manager, hospice.
I agree with you that you need to use quotation marks when quoting a patient.
However, it is not always necessary to quote the patient.
It seems to me that you are documenting things in the medical record that don’t actually belong in the medical record. If there is an abuse allegation, it goes in an incident report and to the proper channels.
When I worked in psych, I frequently quoted patients because it was my job to assess their intent to harm themselves or others. And I needed to justify the interventions I was using that may have been a violation of their rights if used inappropriately. For example, keeping someone in restraints needs a good reason. If I ask the person “will you hurt me or someone else if I remove your restraints?” And they respond by saying “I can’t wait to punch you in your effing face!” That’s a good reason to leave the restraints on and a better one than “pt was agitated.” I’m going to quote the patient.
Quotes are for documenting your reason for the interventions you chose. Not for giving voice to every cockamamie thought your patient has.
When a provider enters an order that is clearly inappropriate, where following the order as written has the potential to cause harm to the patient, it is the legal obligation of the licensed nurse, whether RN or LPN to insist that the order be corrected, and this should be documented in the patient's chart to ensure that this concern has been effectively communicated as their license requires that they do.
Right, but clarification order notes are cut and dry.
Order clarification: melatonin 3mg P.O. at HS PRN etc.
No need to elaborate or use the word error or anything else. Sure; you can - but in my experience it’s a bad idea.
FolksBtrippin, BSN, RN
2,308 Posts
I agree with you that you need to use quotation marks when quoting a patient.
However, it is not always necessary to quote the patient.
It seems to me that you are documenting things in the medical record that don’t actually belong in the medical record. If there is an abuse allegation, it goes in an incident report and to the proper channels.
When I worked in psych, I frequently quoted patients because it was my job to assess their intent to harm themselves or others. And I needed to justify the interventions I was using that may have been a violation of their rights if used inappropriately. For example, keeping someone in restraints needs a good reason. If I ask the person “will you hurt me or someone else if I remove your restraints?” And they respond by saying “I can’t wait to punch you in your effing face!” That’s a good reason to leave the restraints on and a better one than “pt was agitated.” I’m going to quote the patient.
Quotes are for documenting your reason for the interventions you chose. Not for giving voice to every cockamamie thought your patient has.