Documenting conversations with patients

[Dorali, BSN, LPN, RN]

Hi everybody!

I'm a new nurse, still on orientation. Documentation is one of my big fears right now and I have a question about documenting conversations between yourself & a patient. Basically formatting.

Here's why: I had a pt a few weeks ago that was very non-compliant, rude, etc. He was given one more chance to change his behavior and my encounter with him, of course, was his 3rd strike. I had to document the conversation we had.

I wrote it like you would read in a novel:

I said, "Blah, blah, blah." He said, "blah, blah, blah." I did this and that, then he said, "blah blah." Etc.

I had a nurse tell me a long time ago (I was writing a witness statement & asked him to proofread) to write down all the things the pt said, like in a list, then write everything I said below that. He said that whoever was reading it would figure it out, but that just didn't make any sense to me.

So now, here I am over-thinking my documentation that probably doesn't matter this much! Lol

I'd appreciate any tips!! Thanks!!

[AlmostANurse321]

I learned to document like this

I taught patient "ABC"

Patient denied having questions.

Reassess a few hours later

Patient expressed "CDE"

I queried patient about "ABC". Patient refused further teaching and directed profanity at me.

[Sour Lemon]

Hi everybody!

I'm a new nurse, still on orientation. Documentation is one of my big fears right now and I have a question about documenting conversations between yourself & a patient. Basically formatting.

Here's why: I had a pt a few weeks ago that was very non-compliant, rude, etc. He was given one more chance to change his behavior and my encounter with him, of course, was his 3rd strike. I had to document the conversation we had.

I wrote it like you would read in a novel:

I said, "Blah, blah, blah." He said, "blah, blah, blah." I did this and that, then he said, "blah blah." Etc.

I had a nurse tell me a long time ago (I was writing a witness statement & asked him to proofread) to write down all the things the pt said, like in a list, then write everything I said below that. He said that whoever was reading it would figure it out, but that just didn't make any sense to me.

So now, here I am over-thinking my documentation that probably doesn't matter this much! Lol

I'd appreciate any tips!! Thanks!!

I would never document an entire conversation, although I'll frequently include a few quotes as examples of a patient's behavior.

Patient irritable and non-complaint with care, including medication administration. When teaching was attempted, patient screamed, "Get out of here you stupid *****! I don't need any medication! I'm not sick!" Will attempt to re-approach patient at a later time as his moods are known to be variable.

I never include quotes from myself or make judgements (like "rude") in a narrative note. And I try to keep it short and simple.

[Dorali, BSN, LPN, RN]

Thank you both for your input!

For the record, I didn't say anything about him being rude in my nurse's note. That was just to paint the picture for my post here. I knew better than to do that!

So, I'm basically just stating the facts of what happened and the things that the PATIENT says. Not putting in the things that you say, is that because it could potentially be misinterpreted? I know I've had a few text messages unintentionally go bad! Same concept?

[twinmommy+2, ADN, BSN, MSN]

With my aggressive patients, it goes like this:

"While attempting to discharge xyz patient and given discharge medications, patient became hostile towards myself and other staff, saying "abcd.....". I attempted to educate him regarding ghj problem by providing written materials and providing further explanation. Patient continued with hostility (if it is the same tirade he had started with), now throwing water cup at this writer. Writer withdrew from room, patient stating " mnop, I want out of here!". Door opened for patient and allowed to leave the ER ambulatory after continuing to decline to receive discharge medications."

Put down what you can remember from the conversation in quotes if it is relevant to the course of treatment and always report how you responded.

[Sour Lemon]

Thank you both for your input!

For the record, I didn't say anything about him being rude in my nurse's note. That was just to paint the picture for my post here. I knew better than to do that!

So, I'm basically just stating the facts of what happened and the things that the PATIENT says. Not putting in the things that you say, is that because it could potentially be misinterpreted? I know I've had a few text messages unintentionally go bad! Same concept?

It's just not necessary to quote yourself. It's over-documentation. Beyond that, it takes focus away from the patient and puts it on you. It's also very unlikely to be accurate. Few of us can remember a tense exchange word for word. And yes, your words could be misinterpreted ...or in some cases, interpreted accurately and just inappropriate for some reason.

[lindseylpn]

I have a patient with behavioral issues and this is how we normally chart on her.--

Pt agitated and combative during care, yelling and cursing staff, stating "Get out you *****.", Attempts at redirection unsuccessful, calmer after approx 15mins and speaking pleasantly(or appropriately) when staff reentered the room.

We usually don't write out the whole conversations, I normally will quote excessive cursing, threats, accusations, noncompliance etc. This patient freq accuses staff of stealing and this is how we chart that--

Pt accusing staff of stealing her "bag of groceries", frequently reassured by staff that no one is stealing et her response is "I'm going to kill you b****." Redirection unsuccessful, cont to curse et yell out for approximately 2 hours then resting quietly for the remainder of the shift.

In things like a witness statement they usually want word for word statements but, in regular charting a summary will do. (At least that's how it's been done where I've worked)

[Dorali, BSN, LPN, RN]

This is great! Thank you so much!!

Put down what you can remember from the conversation in quotes if it is relevant to the course of treatment and always report how you responded.

Lindsey - I can definitely summarize! Geez that would be so much easier than the torment I put myself through trying to remember every little word.

Sour Lemon - Thank you for your responses! You helped me a lot!

And thank you all for coming up with examples, it makes it so easier to understand. I'll definitely refer back to this post!

[oceanblue52]

I'm a big fan of the phrase "as evidenced by" e.g. "Patient began verbally threatening staff as evidenced by Patient lifting a chair over his/her head, turning in direction of staff, and threatening to throw it." Then state in general terms what staff did in response.

[Emergent, RN]

These are great!

One of my favorite pleasures of the job is quoting the profanity of patients. It's fun!

[hppygr8ful, ASN, RN, EMT-I]

Thank you both for your input!

For the record, I didn't say anything about him being rude in my nurse's note. That was just to paint the picture for my post here. I knew better than to do that!

So, I'm basically just stating the facts of what happened and the things that the PATIENT says. Not putting in the things that you say, is that because it could potentially be misinterpreted? I know I've had a few text messages unintentionally go bad! Same concept?

In psych we document everything the patient says - stay away from subjective words like rude, angry, nice etc.... I will quote expletives exactly and describe behaviors in detail. I also often have to document conversations I have with family members. When teaching I might document "Pat refused teaching, pt verbalized understanding etc.....I actually teach documentation in our facility . Psych has a lot of legality attached to especially with regard to emergency medications and Patients Rights.

Hppy

[CaffeinePOQ4HPRN, BSN, MSN, LPN, RN]

Be careful with over-documentation.

• stick to the basics
  
• only use hospital approved abbreviations (ex. SOB. ha ha ha! I had a pt once (in good humor) commend me for knowing him so well. "Only my wife has been so insightful as to accurately call me a SOB..."
  
• include only the most critical information/details/facts
  
• always ensure to include the exact date/time of what happened/what was said (and, if applicable/possible any witnesses like a fellow colleague)
  
• stay away from objective/biased language
  

A Nurse's documentation is a legal document -- it can be used in court and it can be used against you. Don't panic though, you will get the hang of it over time and with consistent practice. In a few months you will have a clearer understanding of what's importation, what should be included/omitted, when it's appropriate to quote patient and family communications. I think it's great to ask senior nurses to proofread, but you should be confident in your own skills as a new Nurse grad -- I personally like new Nurses because being fresh out of school, your knowledge is fresh and current. What new-grads lack is confidence, and we've all been there in that place of insecurity. They're growing pains in this profession and they will go away... eventually. Ha! In time you might come to call yourself (good-naturedly) a COB like me

Offering superfluous details and information (albeit truthful and however accurate) can unintentionally lead you to shoot yourself in the foot when all you had was "good intentions", and often leads to documentation errors. All it takes is one occurrence of odd phrasing, a word out of place, or incorrect punctuation to offer misinterpretation (or interpretation to another's advantage) to put yourself at the mercy of the person who is actually at fault or an unsympathetic manager/institution. For example, 10.0 mmol/L is very different from 1.00 mmol/L but this kind of documentation error can occur when documentation is too lengthy it's easy for things like this to be overlooked... I have seen this kind of error happen in the documentation of some of my colleagues and brought it to their attention because it's an honest mistake and they should have the opportunity to correct it. We should always try to help each other out as Nurses, it lends to a positive working environment :)

There are some circumstances where it is helpful to quote a patient verbatim, but it shouldn't read like a novel and it should only be included if it actually contributes to help ameliorate/clarify a situation, track/monitor changes in behavior (including abusive traits towards you/others), monitor treatment effectiveness, etc... The list goes on. I am mentioning this as a hypothetical to give you some ideas. Only time and practice will help you improve your documentation skills - in the meantime just be cautious. I used to practice documentation while watching tv. Try watching something ridiculous like The Bachelor, or The Real Housewives and practice your documentation to target the crucial facts. Alternatively, you can always use your old patient case studies from school and practice, practice, practice!

Hope some of this was helpful! Good luck;)