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 am sorry to respectfully disagree. If it comes to court, the jury isn't going to care about the nurse's religious beliefs.
You're right, but I'm going to care.
I am not disagreeing with you, per se. I''m saying that quoting word for word is not absolutely necessary. I do frequently quote word for word, but I rarely have quoted curse words. I'm not saying you CAN'T do it, just that there are other options .
I agree that 'family member acting inappropriately to staff' isn't enough. But 'Daughter approached nurses station, angry that, in her opinion, call button wasn't being answered fast enough. She immediately addressed this RN using vulgar language peppered with four letter adjectives in angry tone making specific and unflattering analogies between this nurse and a laboring dog. Daughter threatened to 'come across the desk' and assault this nurse. Daugher was told that her words and tone were inappropriate and that she would be asked to leave it her actions and words continued to be hostile. Using de-escalation tactics, per hospital policy, daughter was calmly made aware that if her actions and use of foul language continued, that security and or police would need to become involved in this interaction.''
I didn't use either curse word, but I painted the picture specific enough to leave little doubt what was said. I'm not saying your way is wrong, I'm saying there are other ways to be specific if quoting curse words into an official record seems unseemly, as it does to me.
And even if the jury doesn't get EXACTLY what was said, I was specific enough that , even 3 yrs later, I would remember on the stand what was said by what I wrote. If questioned about this line in the chart, I could look the jury in the eye and say "she used the f word and called me a witch but she didn't use a W".
"Daughter approached nurses station, angry that, in her opinion, call button wasn't being answered fast enough. She immediately addressed this RN using vulgar language peppered with four letter adjectives in angry tone making specific and unflattering analogies between this nurse and a laboring dog. Daughter threatened to 'come across the desk' and assault this nurse. I didn't use either curse word, but I painted the picture specific enough to leave little doubt what was said. I'm not saying your way is wrong, I'm saying there are other ways to be specific if quoting curse words into an official record seems unseemly, as it does to me."
ROFL, I must say. I still don't agree, but I do like your style.:)
pt verbally abusive-behavior inappropriate-threatening in nature-informed pt of need for staff safety in order to provide quality care-will notify security as needed-continuing to monitor.
later in shift:
Pt continues to be verbally abusive and threatening bodily harm to staff-charge rn assisting-house super notified. MD aware of poss mental status change. Obtained order for restraints as needed to protect pt from removing necessary medical equipment. Security on alert. continuing to monitor.
Charting exempletives makes you look unprofessional. Hospital orientations usually go over this. If you are confused as to what is approp to chart in pt perm record contact the charge or house super.
Be aware that assaulting a medical professional is a crime just as it would be on the street. You don't have to take it! Don't let anyone tell you different.
Also any family member threatening or intimidating staff should be promptly removed and not allowed back on the unit. Involve security it's their job.
"verbally abusive-behavior inappropriate-threatening in nature" is an assessment and subjective. A description of actions and direct quotes is objective.
verbally abusive-behavior inappropriate-threatening in nature" is an assessment and subjective. A description of actions and direct quotes is objective.
True but is it necessary to be objective in this case? What more CYA is happening if you write in the chart exactly how you were verbally abused or threatened? If there is an actual incident then an incident and or police report will record your statement. People in DT's scream all sorts of threats and never remember a word of it when they are through,we don't chart what they say to us. Psych nurses everywhere would be charting 24 hours a day if they wrote exactly what derrogatories were thrown thier way. Do you chart exactly what happened everytime an elderly man grabs your behind or tells you how pretty you are? Different people are offended by different things but there is a standard in our business of what is inappropriate behavior. When we identify inapprop behavior it's up to us and the MD to find out why this behavior is occuring and how to correct it. That's why the pt is in our care.
pt verbally abusive-behavior inappropriate-threatening in nature-informed pt of need for staff safety in order to provide quality care-will notify security as needed-continuing to monitor.
later in shift:
Pt continues to be verbally abusive and threatening bodily harm to staff-charge rn assisting-house super notified. MD aware of poss mental status change. Obtained order for restraints as needed to protect pt from removing necessary medical equipment. Security on alert. continuing to monitor.
Charting exempletives makes you look unprofessional. Hospital orientations usually go over this. If you are confused as to what is approp to chart in pt perm record contact the charge or house super.
The language might not look pretty on paper, but if that is what is going to save my butt in court than that is what I am documenting. I would much rather have an accurate description in court instead of floundering on the stand, looking unprofessional, when I can't remember the incident in question. I don't think I would I would ask the house supervisor for charting tips unless they were there to witness the activities. I would chart that I notified them, but that is the extent.
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 have been working in a skilled pyschiatric facility and each patient's psychotropic med has an order to check for behavior regarding the patient's med, like thorazine, ambien, klonipin, zyprexa, etc.on one patient. But when I see this patient sleeping with her head on her arms in the dining room, which drug would I attribute this behavior to? All of these meds have a potential for sedation. I'm going to have to ask the DON about this. I am confused!!!!! What do you think?
I have been working in a skilled pyschiatric facility and each patient's psychotropic med has an order to check for behavior regarding the patient's med, like thorazine, ambien, klonipin, zyprexa, etc.on one patient. But when I see this patient sleeping with her head on her arms in the dining room, which drug would I attribute this behavior to? All of these meds have a potential for sedation. I'm going to have to ask the DON about this. I am confused!!!!! What do you think?
You don't have to attribute behavior to a particular med in order to chart it. As a matter of fact, you should not be making that leap at all. Even if you suspect a specific med, you chart something like, "At approximately 0830, patient observed sleeping with head on arms at dining room table. Started 10 mg Ambien previous noc and stated she can't stay awake." You paint the picture but it's not up to you to decide what is cause and effect, even if it seems painfully obvious. In the scenario you presented, her doc could have a barrel of laughs trying to sort out what's what and might do well do reevaluate why he's got his patient on such a fruit salad of meds.
***I just re-read your post and saw that you have to check off behaviors for each med. In my opinion, this is a minefield waiting to blow up for a patient on multiple meds. The only way you stand a chance of making the right call is if the patient has been started on a new med and there is a corresponding new behavior (commonly associated with that med) within a feasible time limit. Even then, is it that one med or is it the interaction with any of the various others? I would approach my manager and ask for very specific P&P on how to address this or suggest that the form be revamped for multiple-med patients to allow for general behavioral charting and the doc can try to sort out which behavior goes with which med. That burden should not fall on you.
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
When a resident goes on a roll like this in my facility, we need to paint a good picture for involuntary admission. If this behaviour has been on going for "X" amount of days, we also include that in our paperwork. Whether or not the "whole" language is used is up to the writer; it helps, but..... :argue:
Specializes in LTC and Critical/Acute Care/Homehealth.
Still being fairly new and knowing that my charting needs LOTS of work, I just wanted to let you know how much I have learned from this thread alone. That being said, I can now understand how charting "inappropriate language and behavior" will not get it, but that is what I WOULD have charted. I can also understand wording and "painting a picture". Charting has been hard for me, due to each of my instructors having their own style. I cannot wait to go back to work and put what I have learned here to work.
You don't have to attribute behavior to a particular med in order to chart it. As a matter of fact, you should not be making that leap at all. Even if you suspect a specific med, you chart something like, "At approximately 0830, patient observed sleeping with head on arms at dining room table. Started 10 mg Ambien previous noc and stated she can't stay awake." You paint the picture but it's not up to you to decide what is cause and effect, even if it seems painfully obvious. In the scenario you presented, her doc could have a barrel of laughs trying to sort out what's what and might do well do reevaluate why he's got his patient on such a fruit salad of meds.
***I just re-read your post and saw that you have to check off behaviors for each med. In my opinion, this is a minefield waiting to blow up for a patient on multiple meds. The only way you stand a chance of making the right call is if the patient has been started on a new med and there is a corresponding new behavior (commonly associated with that med) within a feasible time limit. Even then, is it that one med or is it the interaction with any of the various others? I would approach my manager and ask for very specific P&P on how to address this or suggest that the form be revamped for multiple-med patients to allow for general behavioral charting and the doc can try to sort out which behavior goes with which med. That burden should not fall on you.
Take care,
Miranda
Your post reflected succinctly how I feel. I think what you said about new med and new behavior is logical. I think I will just go with this until I talk to the DON. Thanks
ZASHAGALKA, RN
3,322 Posts
You're right, but I'm going to care.
I am not disagreeing with you, per se. I''m saying that quoting word for word is not absolutely necessary. I do frequently quote word for word, but I rarely have quoted curse words. I'm not saying you CAN'T do it, just that there are other options .
I agree that 'family member acting inappropriately to staff' isn't enough. But 'Daughter approached nurses station, angry that, in her opinion, call button wasn't being answered fast enough. She immediately addressed this RN using vulgar language peppered with four letter adjectives in angry tone making specific and unflattering analogies between this nurse and a laboring dog. Daughter threatened to 'come across the desk' and assault this nurse. Daugher was told that her words and tone were inappropriate and that she would be asked to leave it her actions and words continued to be hostile. Using de-escalation tactics, per hospital policy, daughter was calmly made aware that if her actions and use of foul language continued, that security and or police would need to become involved in this interaction.''
I didn't use either curse word, but I painted the picture specific enough to leave little doubt what was said. I'm not saying your way is wrong, I'm saying there are other ways to be specific if quoting curse words into an official record seems unseemly, as it does to me.
And even if the jury doesn't get EXACTLY what was said, I was specific enough that , even 3 yrs later, I would remember on the stand what was said by what I wrote. If questioned about this line in the chart, I could look the jury in the eye and say "she used the f word and called me a witch but she didn't use a W".
~faith,
Timothy.