Charting Disruptive Patient Behaviors: Are You Objective?

SHGR, MSN, RN, CNS

One of my fellow nurses- let's call her Jane- was overheard complaining loudly this morning. She had received feedback from a physician that one of her chart notes was "unacceptable." She went on to say that she didn't understand why her note was unacceptable. I asked Jane to read aloud the note in question:

"Patient was inappropriate."

"What's wrong with that?" she asked, explaining that this particular patient had been rude the day before, yelling that it took too long for Jane to retrieve her narcotic prescription. The patient had, apparently, shouted a few choice words at this nurse while exhibiting some threatening behaviors.

Jane's documentation, however, did not reflect that.

As nurses, we need to chart specifics, and we also need to be objective. This is straightforward when we are describing, say, a wound that can be measured with a ruler, or a patient's report of pain as "burning in nature rated at a '6' on a 1-10 scale." But when it comes to behaviors, things get a little more difficult. A patient's wrath can evoke a negative response within the nurse that makes it difficult for him or her to remain impartial. Also, nurses may lack the precise vocabulary to explain the event.

Jane told me that she had felt threatened by this patient, describing her as angry and inappropriate.

"Okay, Jane," I said, "what specifically did the patient do or say that made you think she was angry?"

"She started yelling. She was talking loud and fast."

"So you could chart that the patient's speech became louder and faster. What did she yell at you?"

Jane repeated some choice four-letter words that had been addressed to her.

"Great, I would have charted those verbatim. Use quotes. What about her stance? Did she get closer to you, point, stiffen up? What gestures did she use? Did she threaten you?"

Remember that the chart is a legal document and, as such, can be considered evidence. An accurate, unambiguous description of behavior, statements, stance, and gestures will stand on its own in a chart review. If you ever need to testify in court, the specific words will speak for themselves.

The same goes for what patients say over the phone if you are a telephonic nurse: chart specific words in quotes, a tone of voice, or change in tone if that occurs. If words are slurred, chart that.

Knowledge Empowers You

Don't use subjective words such as agitated, upset, verbally abusive, aggressive, angry, or, as Jane did, inappropriate. These are ill-chosen because they are interpretations of behavior, not precise narrative; being subjective interpretations, they mean different things to different people. Instead, chart specific behavior, actions, and appearance. Some examples are:

Pacing
Clenching fists or jaw
Reddening of the face
Trembling of face or body
Stiffening of body
Sudden movements
Changes in vocalizations such as voice becoming louder or faster
Approaching or touching the writer or other staff

Use exact quotes whenever possible, including any obscene or threatening language that was used. One of our allnurses members, Meriwhen- an experienced psych nurse- is clear and unapologetic about this: "I've written out, in unedited and exquisite detail, the most profane things that patients have said...if they're addressing me and/or I hear them being verbally aggressive to others, they will get quoted verbatim. And I never asterisk/ampersand anything out, not even the really bad words.... As they were making threatening statements to us, I documented it all word for word" (Meriwhen, 2013).

After our discussion, Jane was able to compose the following thorough, specific, professional late entry note about the encounter:

Quote

"Patient stated 'It took you too darn long to bring me this prescription.' Patients voice became louder and faster. Patient stepped within 12 inches of this writer and pointed finger in face. 'Tell Dr. Smith that he's a terrible doctor! I'm never waiting this long again!' Patient declined offer to speak with clinic manager and left building without further incident."

May your documentation, likewise, always be descriptive, specific, and accurate, and may your patients always be cooperative.

References

Buppert, C (2012). Nurses: What Is the Most Important Documentation Advice? Medscape Nurses. Retrieved from Medscape: Medscape Access

Meriwhen (2013). Retrieved from https://allnurses.com/general-nursing-discussion/question-can-you-815246-page3.html

(no author). Chart Smart: Documenting a patient's violent behavior. Retrieved from www.Nursing2010.com.

TheCommuter, BSN, RN

Thank you for writing this very informative piece. Nurses in all types of specialties, not just ambulatory care, can use this as a reference for defensive charting.

succinate

Thank you so much for sharing this valuable piece of advise. As a nursing student, I will definitely keep this in mind.

cjcsoon2bnp, MSN, RN, NP

I work in a Psychiatric facility and our patients are identified as having certain "Risk Profile" behaviors which the physician checks off in the order set which include: SI (Suicidal Ideation), SIB (Self-Injurious Behavior), HI (Homicidal Ideation), Sexualized Behavior, Medication Non-Compliance, Aggressive/Assaultive Behavior.

I have often chart "Aggressive/Assaultive behavior" in my notes if I'm referring to the patient's risk profile behavior but I usually put something like "aggressive behavior (patient postured towards staff and stated "I'm going to punch you in the face")" or "assaultive behavior (patient attempted to hit staff with open hand and kicked staff)". Generally to speak I tried to be as objective as possible and chart only the behavior itself, I find that my Psych/Behavioral notes in my Med/Surg & ED job are always objective and use quotes. Words like "aggressive" "assaultive" "agitated" and "inappropriate" never make it into my notes in the ED or Med/Surg. unit but may make it into my notes at my Psych. job depending on the circumstance.

I should also note that "inappropriate" is an acceptable word when describing a patient's affect but it should be qualified. For example: "Patient had a inappropriate affect (patient was observed laughing when discussing death and became tearful when offered dessert after dinner.)"

!Chris :specs:

SHGR, MSN, RN, CNS

cjcsoon2brn said:
Words like "aggressive" "assaultive" "agitated" and "inappropriate" never make it into my notes in the ED or Med/Surg. unit but may make it into my notes at my Psych. job depending on the circumstance.
I should also note that "inappropriate" is an acceptable word when describing a patient's affect but it should be qualified. For example: "Patient had a inappropriate affect (patient was observed laughing when discussing death and became tearful when offered dessert after dinner.)"
!Chris

Thanks, CjsoontobeRN- that is very interesting. In our ambulatory setting, most of our patients are cooperative, pleasant, respectful. However, we have discharged patients from the practice for behavior from time to time, when threats were made.

However, we do have many patients who live with schizophrenia, bipolar disorder, or other (sometimes undifferentiated or undiagnosed?) severe mental illness and I struggle with vocabulary to describe affect and tone of voice. I'll use your technique for charting inappropriate laughing with the qualifying description. Thanks for this!

Meriwhen, ASN, BSN, MSN, RN

Great article even without me in it :)

Charting objectively is a challenge in psych because if you don't document specific behaviors, it can easily be construed as opinion and/or challenged by others. It can also be confusing because one person's idea of "inappropriate" behavior may be another person's idea of behavior that's isn't really too bad.

What helps me is using "AEB" to explain why I've charted someone/something as I did. It's old school, but it works for me. There's always the possibility that someone may disagree with my assessment of a patient, but with "AEB" they can see what behaviors, quotes, observations, etc., that led me to my conclusion.

MrChicagoRN, RN

Nice Article!

I not only address it with staff,

but also regarding psychiatric petitions that are a required 1st step to an involuntary admission. "Brought in by CPD," "disruptive in nursing home...aggressive". "Verbally threatening" can mean a lot of different things. All are unacceptably vague.

SHGR, MSN, RN, CNS

Meriwhen said:
Great article even without me in it ?

Thanks, Meriwhen! I always like to read your posts. You are very insightful and I learn a lot from what you have written here.

bebbercorn

Very good article, I like your examples! I agree that not enough nurses put enough time into their documentation (not that we're given enough time) but quality definitely counts over quantity!

LadyFree28, BSN, LPN, RN

\ said:
Very good article' date=' I like your examples! I agree that not enough nurses put enough time into their documentation (not that we're given enough time) but quality definitely counts over quantity![/quote']
THIS.
This is a great article and reminder that quality trumps quantity ANY day; objectivity WINS with documentation, even if we don't want to put the "choice words" a pt states-it's far better than a vague, subjective word.
My philosophy is a nursing note should be able to paint a picture enough to understand what occurred.

MsLindaW

I am a new Medical Assistant. This is invaluable information for me starting out in my healthcare career. I always want to be accurate and clear in charting information. Thank you!

anon456, BSN, RN

This is great! I was precepting someone last night and we encountered this kind of situation. I had to document on it and so did she. I am going to print out this article and give it to her.

Charting Disruptive Patient Behaviors: Are You Objective?

About SHGR, MSN, RN, CNS

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