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Discussion

avioding criticism in documentation

Just out of curiosity, I was wondering if a nurse had a hostile or combative patient, is it OK to chart the term "belligerent" in reference to their behavoir? I am a new nurse so I am trying to avoid criticism when documenting.

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That sounds more subjective than objective in terms of the verbage. I would document tangible, neutral behavior to paint the picture of your idea of beligerent. Waves arms, kicks legs, strikes out towards staff, spits, attempts to bite, states, ... " ' with direct quotes indicating the verbage used by patient...' " ... does this help? be objective, not subjective. I know it's hard sometimes!

Just out of curiosity, I was wondering if a nurse had a hostile or combative patient, is it OK to chart the term "belligerent" in reference to their behavoir? I am a new nurse so I am trying to avoid criticism when documenting.

I would document their actions or words and leave out my assessment. "Belligerent" may have different meanings for different people. I would consider it a judgment.

Just out of curiosity, I was wondering if a nurse had a hostile or combative patient, is it OK to chart the term "belligerent" in reference to their behavoir? I am a new nurse so I am trying to avoid criticism when documenting.

"Belligerent" is a pretty subjective term, and so, I would not use it. Better, objective verbage includes: "pt standing at side of bed yelling, making statements about wanting to harm caregiver staff, flailing his arms, and attempting to hit RN. Family notified. Security called to assist."

HollyVK

I describe, rather than label behaviors.

"Pt speaking in loud angy voice with tense expression, saying F*(& you repeatedlt to staff."

"Pt slapping at staff during assessment"

I find a few direct quotes and painting a picture of what is going on is the best way.

The word belligerent doesn't actually describe very much. As other posters have said, describe exactly what was said and done. And yes, if the patient says "F-you" or uses other profanity, I'd put that in quotes and write exactly what was said.

"Belligerent" may mean argumentative to me but to you may mean that he was trying to punch you out. That's why "patient attempted to strike nurse and spat at nurse" is much better to use.

Paint a picture with your words, so that anyone reading it can see just exactly what was happening.

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All of the above are excellent pieces of advice.

Here's one more, straight from a nursing instructor I had many years ago: If you are ever tempted to use negative or judgmental terms in your documentation, try visualizing your chart notes, in letters three inches high, displayed on the overhead in a court of law for all to see.:chair: Believe me, it's prevented me more than once from penning remarks that I probably would have come to regret.

Dealing with human beings can be utterly exasperating; it's not easy to be completely objective when you've answered the same call light for the fiftieth time in one shift, or been threatened by a patient or family member who outweighs you by eighty pounds. Just remember, when you chart in the medical record, it's as permanent as if it were engraved, and you do NOT want those heat-of-the-moment feelings to jeopardize your case or make a jury question your professionalism if they were ever to come to light in a public arena.

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