Charting for behaviors

whipping girl in 07, RN · Aug 26, 2005

When I chart on behavior or inappropriate language, I am as specific and descriptive as possible. If there is just one incident, I might say something like "pt cursing at this nurse; asked to use more appropriate language; pt refused." However, if there are many incidents, I use direct quote and describe events as they happened; I don't just say "inappropriate behaviors/language."

Hope this helps.

Super_RN, BSN, RN · Aug 26, 2005

Let's see here...you charted that there was vulgar language used towards staff, and there was. So what's wrong with that picture? Nothing as far as I can see. When people use vulgar language towards me, I chart specifics. If someone told me they were going to kick my f****** a$$, then I would chart exactly that, to cover my own a**. I believe one must chart accurately and defensively at all times. You chart what YOU deem appropriate. Everyone has different charting styles, but I see nothing wrong with what you charted, in my opinion.

Jaime

Rohan · Aug 26, 2005

Being more specific on each incident would seem more helpful to me.

MS._Jen_RN, ASN, RN · Aug 26, 2005

I too am specific because what is "inappropriate" language or behavior to one person may be different to another. Also, in your patients case she/he was threatening physical violence, which is not specified under inappropiate behavior/language. I can call you nasty names, which is inappropiate, without threatening you. Also, the specific word choice of the patient may show better their level of inappropriatness (*is that even a word?*) Calling someone a cow is different than call them a f#c&in' B!t@#.

(note: I used the cute little symbol substitution thing here to avoid being "inappropriate" *he he* but in my actual charting I use the real words- uneditted. If someone is to get offended, I'm sorry, but they should have been there when those lovely words were directed at me.)

~Jen

rn/writer, RN · Aug 26, 2005

Charting that patient used inappropriate language or engaged in inappropriate behavior is inadequate for two reasons. First, it is a subjective report. What seems inappropriate to you might not appear out of line to someone else and vice versa. Second, it doesn't convey enough information to be helpful. You aren't just tattling. This kind of charting is meant to document the patient's ongoing inability or unwillingness (or both) to coexist and cooperate with staff and fellow residents. It can ALSO give clues about the patient's state of mind and reveal things like anger, anxiety, delusional thinking, and other concerns. It's hard for a clinician to read between the lines when the "lines" aren't presented.

Certain types of speech or behavior can help pinpoint what parts of the brain or psyche are affected and can even, at times, be a kind of code language for what is happening to the patient. Then again, it could just be somebody "going off" for the umpteenth time. Staff members might interpret the raw data differently if, indeed, they have that data to work with.

I would chart inappropriate language, especially threats, verbatim. You needn't transcribe an entire diatribe but give enough of a sample to convey the whole. And I would describe inappropriate behavior in enough detail for the reader to make the judgment that it is inappropriate. In nursing school, I was always taught to describe what I saw without attaching value judgments or leaping to conclusions.

One other thing. I have been an EMT for many years and we often have to radio or call medical control for permission to do various things. Our med control doc has taught us over and over again to "paint the picture" for him. This means giving him enough info that he can see what is taking place and prescribe accordingly. I have tried to carry this over to my hospital charting and have found it to be a really useful mindset.

Miranda

elthia · Aug 27, 2005

We have a resident that has been on charting for behaviors for an extended period of time. Last night she was on a roll and I charted that used "vulgar language towards staff" and "physically threatened CNA's" (she told the CNA "I"m gonna kick your f*cking a**!" to be exact). Let me clarify that this was not an incident report, we chart every shift monitoring her behavior.
The nurse I was working with said my charting was fine but the nurse comming on said that what I did was wrong and I should have used "inappropriate behavior" and "inappropriate language" and left it at that. I see those two statements as being too vague and I should call it as I see it. I'm a very new so I'm open to suggestions and have no problem being corrected by nurses with more experience.
So, did I chart correctly or should I take the NOC shift nurses advise?

I would chart exactly what was said. I would also chart the patient's body movement's, i.e., " the patient stepped up to CNA, was withing 6 inches of CNA's face, using loud tone of voice, right hand clenched in fist and shaking fist at CNA's face." That way if there are legal ramifications, no one can doubt exactly what went on.

I've been attacked by patients before, be very careful and very descriptive in your charting, it will save your a$$ if a situation should escalate to the point where the patient cannot be reasonably controlled or calmed down.

not now, RN · Aug 27, 2005

Thank you everyone for your help. I appreciate it.

When I was in school the LTC facility we did clinical's in didn't let us chart and all the acute care facilities were check charting. I'm a brand new nurse so I'm a little uptight about making sure I do things right and covering all my bases.

bellcollector · Aug 27, 2005

Elthia is exactly correct. There is a course out there called "Chart Smart" it teaches how to chart so that charting would hold up in court if need be. It encourages using word for word with quotation marks. Being very descriptive as elthia described. Describe every thing very factually without judgement or emotion. When we chart we are suppose to be painting a detailed picture so that anyone reading it can picture exactly what happened. It also never hurts to keep your own journal of events such as these using initials only so as not to have any identifying names or such outside the facility. This is something state recommended to me when I was having some concerns that incidents may be being hidden. This one was actually a life saver as I am currently a witness in an event and my journal has helped me remember and keep the facts straight. I hope this helps. Bell

ZASHAGALKA, RN · Aug 27, 2005

I'm sure the previous posters have a point. But. I'd like to think that I have enough tact and intellect to exactly describe a comment without actually writing a curse word into my charting.

I'm a religious person and I believe my actions are an example. I would be appalled to have to defend in Court, to my boss, to a family member accessing the chart, to a co-worker, or to anyone else a curse word written in my handwriting.

I think your charting should be more specific but I think you can describe the mud without placing an example of it on the chart for others to also get dirty. . .

~faith,

Timothy.

DusktilDawn · Aug 27, 2005

Here are some links for Charting tips:

At FindArticles there are 4 articles here on charting:

http://www.findarticles.com/p/search?qt=Charting+Tips+1&tb=art&qf=free

Do's and Don'ts of Nursing Documentation, also includes links to 10 other articles & books:

http://medi-smart.com/documentation.htm

Narrative charting nursing:

http://narratives.100w.info/narrative-charting-nursing

There are also 2 threads at allnurses on charting:

https://allnurses.com/forums/showthread.php?t=39165

https://allnurses.com/forums/showthread.php?t=2083

ShayRN · Aug 27, 2005

I'm sure the previous posters have a point. But. I'd like to think that I have enough tact and intellect to exactly describe a comment without actually writing a curse word into my charting.
I'm a religious person and I believe my actions are an example. I would be appalled to have to defend in Court, to my boss, to a family member accessing the chart, to a co-worker, or to anyone else a curse word written in my handwriting.
I think your charting should be more specific but I think you can describe the mud without placing an example of it on the chart for others to also get dirty. . .
~faith,
Timothy.

I am sorry to respectfully disagree. If it comes to court, the jury isn't going to care about the nurse's religious beliefs. They are going to want to know what was said or done. I don't think "inappropriate" covers it. If a patient calls me a "f*&^%#@ B*(^% I am going to document that. Once, I had a family member come up to the desk, ask who was in charge and then start with the "F bomb" because her father put on his call light and someone didn't come quick enough. (He needed a bed pan.) I really thought that she was going to physically attack me, so I called the police. She sent a letter to the hospital administration saying that I was cursing at her and physicaly threatened her and only called the police in retaliation of her complaining. The ONLY thing that saved my behind is my documentation of the incident. If I had put "inappropriate behavior and language" instead of "family member (daughter?)upset that call light wasn't answered quicly enough. At desk calling charge nurse a F*(& B&^% and threatening to fly over the desk to kick my a$$ and take me down." Now, hmmmm, what paints a clearer picture as to the mentality I was dealing with on that particular day? You need to chart SPECIFICALLY what happen, vague documentation may be prettier but certainly won't cut it when you need to explain yourself.

On a side note, I take it one step further. If a doctor is verbally abusive and curses at me, I document THAT as well. I even tell them, listen, if you don't change your behavior this second, I will document in the patient's permenant record our conversation WORD FOR WORD. I don't do that if they just get smart of cocky, just abusive. Believe me, it only takes once and they don't do it again.