Documenting patient behavior

[SNgirl21, BSN]

Hi, I was just wondering- Is it okay to document a patient as being impatient of frustrated from observation? I'm not sure if this is making too much of a judgment against the patient?

Thanks:)

[Tacocat, ASN, RN]

IMO you can document that the patient "expressed frustration" or "verbalized frustration" or that they appeared agitated or displayed sx of agitation or anxiety. Impatient isn't really a word I'd use?

It would depend on the context, you would need to include WHY the patient was unhappy and any steps to resolve the issue. "Pt verbalized frustration that he could not receive his 8PM dose of oxycodone at 5PM. Pt reports 7/10 pain in left ankle. Offered patient ibuprofen PRN, pt declined. Provided hot pack for nonpharmacological pain management."

Or "Pt presents as anxious and reports that he is waiting for the doctor to discuss his test results. Offered supportive listening and allowed patient to express his concerns."

[Tacocat, ASN, RN]

Or "Pt NPO after midnight due to endoscopy scheduled at 7am. Pt angry and states he is thirsty. Provided pt education on need for NPO status prior to procedure. Performed oral care for patient comfort."

[SNgirl21, BSN]

9 hours ago, WhaleTails said:

Or "Pt NPO after midnight due to endoscopy scheduled at 7am. Pt angry and states he is thirsty. Provided pt education on need for NPO status prior to procedure. Performed oral care for patient comfort."

Thanks?

[verene, MSN]

I'd document the behavior or verbalization that makes you believe the patient is frustrated. That way it keeps the documentation fact based and doesn't impose your interpretation of the patient's emotions.

Rather than chart patient "inpatient and upset" you want to get "why" of the situation and the specific behaviors and statements.

Example: Patient asked for test results from AM lab draw 7 times in last hour; became tearful when informed that results are still pending and have not yet been released from lab. Reassured patient that results will be shared with them once known.

I also really like direct quotes.

Example: Patient declined vitals signs telling RN: "***ing *** get out of my room now or I'll break your arm!" Vitals not checked; PMHNP notified of increased agitation and verbal threats by patient with request for PRN medication orders.

[SNgirl21, BSN]

On 10/26/2019 at 4:03 PM, verene said:

I'd document the behavior or verbalization that makes you believe the patient is frustrated. That way it keeps the documentation fact based and doesn't impose your interpretation of the patient's emotions.

Rather than chart patient "inpatient and upset" you want to get "why" of the situation and the specific behaviors and statements.

Example: Patient asked for test results from AM lab draw 7 times in last hour; became tearful when informed that results are still pending and have not yet been released from lab. Reassured patient that results will be shared with them once known.

I also really like direct quotes.

Example: Patient declined vitals signs telling RN: "***ing *** get out of my room now or I'll break your arm!" Vitals not checked; PMHNP notified of increased agitation and verbal threats by patient with request for PRN medication orders.

Thanks