Charting a Staff/Family Conflict

leslie :-D · Mar 15, 2008

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

yep, i've done that too.

leslie

imanedrn · Mar 15, 2008

Here's what I hear across the board: new grads chart to much. I think we learned in school that you should chart EVERYTHING you do, and "If you didn't chart it, you didn't do it." Naturally, we assume details are important. I've learned that more experienced nurses don't necessarily agree, esp. for the legal ramifications. What I've been told is that you want the facts there, you don't want to be vague, but you also don't want to tell them everything because - as another poster commented - it could leave open a LOT of room for questions and blame - esp. at you.

It's such a precarious road, but - ultimately - you have to do what works for you. Take the suggestions and decide what you want to do with them. In the end, it's your license, so do what YOU think is right for yourself, your beliefs, and your career.

dcampbell · Mar 15, 2008

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

I would want to have a copy of my own notes also in case they "disappeared" but is that legal? Would the hospital encourage/allow nurses to do that? If the hospital records are requested for court and they have been "lost" would a copy of your notes be acceptable in court? Has anyone ever heard of of case like that (only record of events were from a nurses' photocopy)? Just wondering from those of you that are more knowledgable about legal things than I am. Thanks.

miko014 · Mar 16, 2008

I would want to have a copy of my own notes also in case they "disappeared" but is that legal? Would the hospital encourage/allow nurses to do that? If the hospital records are requested for court and they have been "lost" would a copy of your notes be acceptable in court? Has anyone ever heard of of case like that (only record of events were from a nurses' photocopy)? Just wondering from those of you that are more knowledgable about legal things than I am. Thanks.

I've always been told NOT to save anything - because they can be used in court. If you save any paperwork, it can be subpoenaed (is that right???) and used as evidence in court.

I chart by exception. A lot of new grads (and some not-so-new nurses as well) chart way too much. It's not necessary to say, "Pt ate 50% of breakfast, sat up in chair, watched television, had assistance with bath, etc". At least not on my charting. There are checkboxes for everything, and as long as it's marked in a checkbox, it's charted. That being said, a conflict is an exception to normal, and I chart it all as objectively (and briefly) as possible so that someone who reads it later will be able to know exactly what happened without feeling that there is "blame" attached, and also without having to read a novel. In your situation, I would have charted a short paragraph about what happened and what I and the MD did. Since I don't know exactly what you wrote, I can't give an opinion, but I would have done more than what your preceptor did. I chart by exception, but I also do CYA charting!

elizabells, BSN, RN · Mar 16, 2008

I chart like a madwoman, myself. In cases of conflict, I use this pattern:

"Mother stated "XXXXX" This nurse [how I was taught to refer to myself in charting] stated "YYYYY" Charge nurse notified, MD notified [if applicable, but I ALWAYS notify my charge]"

Natkat, BSN, MSN, RN · Mar 16, 2008

A lot of new grads (and some not-so-new nurses as well) chart way too much. It's not necessary to say, "Pt ate 50% of breakfast, sat up in chair, watched television, had assistance with bath, etc".

Ha ha! Oh yeah, that looks familiar. :imbar

That's because we have had that kind of charting pounded into us nursing school. Many is the time someone has been berated in post-conference for not charting enough. I had one instructor who made six students trudge back to the floor to do more complete charting while the rest of us got to go home. It's no wonder they chart so much. We've been traumatized for not doing more. :bluecry1:

pagandeva2000, LPN · Mar 16, 2008

I would chart objectively, with the facts, quotations and who I contacted. Usually, the familes and patients with squeaky wheels are the ones who try to sue. I haven't had to go to court to defend myself, yet, but, I'd rather chart at least major details than be evasive, because I may not remember what actually happened years later (we get cursed out for so many situations that one story may jumble into another).

pagandeva2000, LPN · Mar 16, 2008

If I did have a reason to copy my notes, I would not mention it to anyone...they would be under my own private files, and would not mention this to anyone whether it is legal or not. Just my opinion.

TazziRN, RN · Mar 16, 2008

Conflict with dad, meeting with social services, conflict resolved.

Atty: So did you tell the family that if they didn't wash their hands frequently the pt would be at risk for infection?

Nurse: Yes, I did.

Atty: Can you show me where you charted that?

Nurse: No

Atty: So you can't prove that you told the family about the handwashing?

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Conflict with dad, (fill in details), meeting with social services, conflict resolved and dad agreed (fill in details).

Not a whole lot the atty can ding you on with this one, right? Poor or minimal charting will not get you out of testifying, instead it can get you raked over the coals.

denicu · Mar 17, 2008

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!

When it coms to staff/conflict-i would chart the min and document resolved but i assure you there will be another conflict tomorrow or the day after and nothing will be done. Social worker should be contacted but as a pt no matter how he or she behaves-he is the customer and he is always right. A month ago the mother of a baby threatned to "smack" a nurse . She explained to the mom that she considered that statement a threat and she was going to call security. The mom left the unit. When it was brought to the nurses manager's attention she made it sound like the nurse must have done something to cause the mom to want to "smack" the nurse.

miko014 · Mar 17, 2008

Maybe peds is different from adults (well, duh, haha!), but why do you guys keep saying you contacted the social worker d/t a family/staff conflict? I have never, ever called the SW because a family member or pt flew off the handle at me. I have called security, I have called the charge RN, I have called the house sup, but never a social worker. I'm curious as to what the SW would do in a situation like this - I mean in general, not just in the OPs case.

denicu · Mar 17, 2008

Maybe peds is different from adults (well, duh, haha!), but why do you guys keep saying you contacted the social worker d/t a family/staff conflict? I have never, ever called the SW because a family member or pt flew off the handle at me. I have called security, I have called the charge RN, I have called the house sup, but never a social worker. I'm curious as to what the SW would do in a situation like this - I mean in general, not just in the OPs case.

In most NICU i have worked in there is a social worker assigned to each baby. They assist the moms with needs-insurance, wic, discharge needs . If they need transportation to come and see their baby-the SW will provide vouchers or tokens. They are usually a very good support system for the parents esp difficult parents. l