documentation

[roxie144]

If you are taking care of a patient who is non-compliant, when giving education stares out the window, paying no attention, throws a fit at every meal because they are on a fluid restriction/diabetic diet, tells you he is going to eat, you give the insulin, he takes a bit then says it's **** and stops eating, who refuses to clean up then yells at you later for not being cleaned up, who curses at you all day, they are AOX3, ambulatory, and actually told me during my shift after throwing a fit over sugar free syrup tells you, and I quote, "i'm going to **** on the floor so you have to clean it!" So my question is do you document his statements word for word including all the foul language?

[caliotter3]

Yes, you do. Word for word. And document the behavior using objective language.

[Dixielee, BSN, RN]

Yep, I would definitely not clean up the language for the chart, just put quotation marks around it. Cover yourself. If you have not already spoken to your manager and the physician you should do it ASAP. You should not have to put up with that behavior.

[Sanuk]

Yes, when pts are abusive, I use direct quotations, note any witnesses, and also nonverbal behavior - lunging at staff, raised fists, etc. Sorry you're having to deal with this - at least in the ER we get new pts every shift. Most of the time anyway.

[DixieRedHead, ASN, RN]

Direct quotes in quotation marks. Always, every time.

[netglow, ASN, RN]

After something similar, I documented and then notified MD. MD did rounds and came out of pts room and sat down at the computer and wrote a very calm note of physical/labs/mental assessment (patient stabilized), and then says that it appears that Mr. Patient does not see value in receiving any of the services that this MD, the nursing staff or this facility has to offer (lists quotes from Mr. Patient). Then he wrote discharge orders. :)

[psu_213, BSN, RN]

Direct quotes in quotation marks. Always, every time.

Totally agree. If they come back later and try to say they suffered poor customer service, your case against them is going to be strong if you were to write "pt stated to this RN 'you are a total *'" (with the acutal word in the place of the *) rather than stating "the pt treated staff rudely." The latter could be mean that the RN just has a thin skin. The former is a pretty strong statement that the pt has issues.

As for the teaching, if you can chart that the pt volutarily ignored the teaching and volutarily went against dietary restrictions (such as eating candy that family brought in), then it is unlikely to fall back on you when when return in a month in DKA.

[turnforthenurse, MSN, NP]

As for the teaching, if you can chart that the pt volutarily ignored the teaching and volutarily went against dietary restrictions (such as eating candy that family brought in), then it is unlikely to fall back on you when when return in a month in DKA.

All you can do is educate; you cannot force someone to adhere to dietary restrictions. I have had a lot of patients in the past who are non-compliant with sodium restrictions (and they are extreme CHF-ers) and all I did was document my education and document their non-compliance. Save yourself.

[merlee]

Word for word. As exact as possible. Get witnesses, call your supervisor, the doc and administration. Patients may be asked to leave, even if there is still much to do.

Non-compliance is one issue, abuse is something else. I may not adhere to my diet, but I do not abuse the people who are trying to help me.

No one is entitled to be ugly to the staff.

[Dixielee, BSN, RN]

After something similar, I documented and then notified MD. MD did rounds and came out of pts room and sat down at the computer and wrote a very calm note of physical/labs/mental assessment (patient stabilized), and then says that it appears that Mr. Patient does not see value in receiving any of the services that this MD, the nursing staff or this facility has to offer (lists quotes from Mr. Patient). Then he wrote discharge orders. :)

LOVE this Doc!!

[TonyaM73, ASN, RN]

I would bring a witness in each and every time I went into that room. I would quote pt's exact words and who you brought in with you.

I will never understand the mentality to treat the people that are trying to take care of you like dung. Helllooo, these are the people that are in charge of your care and your medications??? I would never treat any of my pts any differently and strive to take the best care of all of them, but how do they know that I don't have a malicious streak in me???

[talaxandra]

I'm sorry you've been hit with the trifecta of dismissive, wilfully disinterested in learning, and abusive - the latter makes it particularly hard to maintain a professional attitude, at least for me. And everyone's right, you can't go wrong documenting everything verbatim, as objectively as possible.