Charting a Staff/Family Conflict

[purplekoolaid]

I'm a new grad and I've been working in PICU since Janurary. I have a question about charting a family situation, and sorry this post is kind of long!

Yesterday at work, I was taking care of a pt. whose family (mainly Dad, who was a former EMT of several years) has been having a lot of conflict with other staff, including physicians and other RN's. Pt had been intubated for several days, and was finally extubated the day before this all happened. The pt had like 5 siblings and they had all been in the room throughout the hospitatlization, touching him excessively and talking loudly telling him to "wake up!". When I found out sister was in ER during my shift with pink eye and similiar flu-like respiratory symptoms, I told the physician because I knew that they had all been in such close contact and I was worried about pt being reinfected. Dr went in to the room to talk to the Dad and siblings about how they need to wash their hands before they have contact with pt, and Dad exploded, saying that he didn't appreciate how Dr "talks down" to him and wife and treat them like they're stupid. He went on, yelling about how they only reason they're even at this hospital is because they have no other choice. Dr explained to him his other options, he said he wanted to transfer hospitals, so we called social work and had a staff/family meeting, and eventually the conflict was resolved for the time being without a hospital transfer.

I'm still on orientation so later in the day the nurse I was working with glanced quickly at my charting and asked me about why I had charted so much about what happened. I had just charted the facts, what Dad said and what Dr said, that we had a meeting with social work, and conflict was resolved, bascially what all I just typed without placing blame. She was surprised I charted so much and told me she just would've charted something like "Conflict with Dad, family meeting held with social work, conflict resolved" without much detail. When I asked her why, she said it was so that if it went to court, she wouldn't have to testify or anything. We asked another nurse who also agreed to do it the "short way" to avoid a court date. I guess I thought it was important to chart what I charted because it had an effect on the pt's care (his VS elevated every time family was in room overstimulating him, other RNs had been having problems with him on a daily basis being verbally violent and one time physically violent, and had to call security a few times, all of which had been previously charted).

I guess my question is how do I chart a situation like this? Did I chart too much detail? Thanks in advance for the feedback and help!

[leslie :-D]

you're probably going to get varied answers.

speaking for myself?

anything that directly affects the pt, i chart on.

i do try to keep it short, but am specific.

what if your pt comes down w/conjunctivitis, or worse, pneumonia, and dad becomes irrational?

you just never know where these events/conflicts will lead.

do what you're comfortable with.

it's your license.

leslie

[Natkat, BSN, MSN, RN]

Yeah I think in this case less is more. There won't be as much for their lawyer to pick apart. The more you write, the more a lawyer could ask you "so what did you mean when you wrote.............." There is more for them to interpret negatively.

[caliotter3]

A nurse supervisor I once had was discussing charting and lawsuits with me once. She said that a lawyer tore her apart for her use of one medical term. I think you're darned if you do and darned if you don't, so chart the way you think you should. I wrote a page and a half about an incident one time and swallowed my tongue when I read some of my charting quoted in the newspaper. It was apparent that the outgoing DON had leaked medical records to the press when she made her dramatic departure. I was stunned to say the least.

[Blee O'Myacin, BSN, RN]

Chart what you are comfortable with charting, as long as it is complete. I think that you would have a tougher time in general having to fill in gaps, rather than explain the finer nuances of your narrative.

There was nothing wrong with what your preceptor suggested. I probably would have charted that the patient's sibling was at bedside with obvious upper respiratory symptoms and reddended eyes with pruluent discharge, proper handwashing reviewed by RN and MD with patient and family... etc. (So in short, it probably would have been a longish narrative - and I would have charted it in the education area as well - might as well get some brownie points while you're at it...)

I chart every time a patient or family member is hostile or abusive. ie: 'Pt.'s daughter states that "nothing" was done for her mother. At time of conversation, patient had just returned with RN from CT scan. RN explained tests already completed with pt. and her daughter, and kept patient and family informed of any delays in treatment. Patient's daughter requested broth and crackers for her mother who, as per daughter, "has not eaten in three days". Pt. is NPO for testing and states that she is "not hungry"... etc. It's a good thing I type 90 wpm... and I have yet to be dragged into court over broth and crackers. But my point is, the patient's family who is demanding why "nothing" has been done, when all they mean is that they are PO'ed about a hallway bed when they are vomiting or have a migraine because all the monitored beds are being used by patients who need monitors, are the people who walk outside and call the nurse manager to complain. I want my manager to be able to pull my charts and see for herself what happened so that I don't waste anymore time sitting in her office when I could be polishing off that last container of bonbons..

Blee

[leslie :-D]

right on, blee.

as a rule, any event that has negative implications, cya and chart.

leslie

[gonzo1, ASN, RN]

It is better to chart than not to chart. If for no other reason than it refreshes your memory in court.

Remember that in pt care, if it wasn't charted it didn't happen. I usually state "voicing concern" instead of other phrases like "complaining, ********" because then the lawyers can't say you felt negatively toward the pt or family.

Also remember that as long as you are working within the standard of care they can't touch you.

If you are not sure if a situation is being dealt with within the standard of care then always check with your supervisor and document if at all fitting that the situation was dealt with the cooperation of your supervisor.

[EricJRN, MSN, RN]

she just would've charted something like "Conflict with Dad, family meeting held with social work, conflict resolved" without much detail.

It's always difficult to determine which types of family issues are relevant for charting, but if you decided to chart something, I wouldn't go about it like this. This sentence would raise more questions than it would answer.

Think in terms of specific observable events rather than assigning descriptors like conflict. We would never think of charting, "Patient had two episodes this shift, but the patient has recovered now." Without clarification in the form of specific observations, both examples are too general for anyone to know what you really mean.

[leslie :-D]

If you are not sure if a situation is being dealt with within the standard of care then always check with your supervisor and document if at all fitting that the situation was dealt with the cooperation of your supervisor.

hmmm.... that is a touchy situation.

i've been in situations where clearly, the standards of care were not being met.

but i did document that i voiced concerns to x, y and z.

leslie

[loriangel14, RN]

I would have charted the episode as accurately as I could. Being vague is not acceptable and is no use to anyone. Where I work any important family interactions are charted in a focus note(we use Meditech) and if subsequent shifts need to know what has been going on they can read the note. Also when giving report we can advise the oncoming shift there an issue and advise them to read the note. Saves having to retell the whole story in report. I have seen it also used to refute family members that say they were not informed of certain things. If we contact family to relay information we make a note so they cannot say they weren't told. We had a pt pass away with no family present and they raised h*** saying they were not informed their loved ones death was imminent. Luckily the nurse that phoned repeatedly and left many unanswered messages had documented this so the family backed down. ( Sorry if that was a bit off topic).

[Altra, BSN, RN]

I have to shake my head at the notion expressed by the OP's coworkers that I shouldn't chart so that I won't be called into court ... that's cowardly, IMO. If there is going to be any legal action regarding a patient's care I certainly hope it's not as a result of my care. But if there is legal action I can promise you that my charting will paint a clear picture of the patient's condition and any/all issues surrounding the patient's condition during the time the patient was in my care.

I chart concerns expressed by family and patient & family education. I chart, to the best of my ability, which specific family members/visitors are at the bedside with the patient and when they arrive and leave.

I have been subpoenaed twice in my as yet brief career -- a direct result of working in an urban trauma center ED. I routinely perform legal blood draws and document injuries sustained secondary to assaults, alcohol-related MVAs, sexual assaults, and encounters with law enforcement. I have been witness to patients explaining the criminally-related circumstances that caused them to be in the ED, and naming their assailants or co-actors. I'm a nurse, not an attorney or law enforcement, but it is perfectly acceptable to me to play a role in the wheels of judicial proceedings.

If it were not, I would need to find an entirely different setting in which to work.

The OP's circumstances are different from mine, but family conflicts, particularly when expressed in the presence of the patient, are definitely relevant to the patient's holistic condition and need to be documented, IMO.

[lindarn]

I would also have gone so far as to make copies of my nurses notes, to protect myself in case my nurses notes accidently "disappeared" from the chart.

Lindarn, RN, BSN, CCRN

Spokane, Washington