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Discussion

documentation

greetings everyone. i wanted to get some feedback on a situation i recently encountered. i was recently reprimanded about documentation in a patient's chart. i have been an lpn for 19 years and while i am not perfect, i think my documentation is clear. i have always documentated things my patients have said in quotes. recently while caring for a very beligerent patient, the patient called me a "f****** b****". we had been told to document carefully as psych was coming in to do a consult. i documented word for word what the patient had said. when my manager reprimanded me, she said that i should not have written exactly what the patient said but simply stated that the patient "used vulgar language". i personally feel that everyone will have a different perceptions of what "vulgar" is and that quoting the patient was the right thing to do. i have been out of school for a while, so perhaps i was wrong to quote directly. any opinions? thanks!!

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I was taught to use direct quotes as much as possible. I have used the more general comments when there was too much to write and/or I could not pin down the exact quotes I wanted to place in the charting. Since you knew that there was to be a consult, as far as I am concerned, all the more reason to use direct quotes. Just exactly what is your supvr trying to sugar coat and why?

You documented correctly in your chart. We can not just say a patient became delusional because what is delusional to some is not to other, if a patient told me she was a queen, I may find out later she may have once been prom queen or paranoid, paranoid of what/who for example all those who believed the CIA didn't have special prisons and then we find out they do. What is vulgar to some may not be vulgar to others so quoting a patients with " " is correct. I tell those who question me about notes if you don't like it write it yourself.

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