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Discussion

Charting

I work in the ER. I was curious as to all nurses about how u document certain things. I had a pt screaming profanity. Now do you document word for word what they say?? And put it in quotes?? Last time I was in nursing school was 10 years ago. Just wondering how u guys do it. THANKS :)

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    I haven't had that happen but I would chart it in quotes most definitely.

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    "Pt screaming and yelling profanities at ER staff." If there are any explicit threats, then I chart them as a direct quote.

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    Agree with the post above - this is exactly the dividing line that I use. I avoid filling up a chart with expletives (though sometimes they are so creatively worded, it's tempting ...) until a direct threat is involved. Then I quote directly - Patient states "I'm going to knock your ******* teeth out."

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    Well they said "you are a stupid f---King doctor nobody here knows anything and a f---king house fell on My head". Ended up discharging this princess with the help of our detail officer.

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