Documentation

CompleteUnknown · May 18, 2011

Agree that if you chart the behaviour you also have to chart what was done about it. I've seen so many charts where the nurses are faithfully recording the behaviours shift after shift but nothing is ever written about what was tried to help manage the behaviour and whether or not it worked. This just makes it look as though nothing was done and the residents are running wild while the staff do nothing except write it down! It really does look bad.

I've had nurses say to me that they 'don't care how it looks, something needs to be done'. That is missing the point, to get something done there needs to be a record of what has been happening AND what, if anything, helps even a little, and what doesn't help at all.

Another thing to remember is that many, if not most, interventions to manage behaviour are an ongoing thing. Some staff seem to think that you should only have to do something once and from then on the behaviour should stop so they keep documenting the same thing over and over because the resident is 'still doing it'.

There is an art to documenting challenging behaviour and staff need to have an understanding of what are and what aren't appropriate interventions. Telling a resident with advanced dementia that their behaviour is 'not appropriate' is not helpful but it's amazing the number of times you will see staff document that that's what they did.

Any or all of the above could be what your DON is on about. If there are interventions in place (and documented on the care plan) to manage a particular behaviour and those interventions work to manage or reduce the behaviour, I would say that you would only need to document that behaviour if the interventions stop working or the behaviour is becoming more frequent despite the interventions.

If you really think the DON is wanting you to omit important information from the chart, that's another problem entirely. I'd talk to her again if I were you, to make sure you know what she means.

CapeCodMermaid, RN · May 18, 2011

When I have a resident with behavior issues I have to call my DON to ask if I should be charting this or not..she said we have to monitor what we chart otherwise the state will address it.. is omission legal???

If my nurses had to call me every time they charted a behavior, no one would get anything else done. Chart what the behavior was: screaming or being intrusive, what you did: redirected or gave PRN meds, and the outcome of your intervention..resident stopped screaming or whatever.