Documenting Pt statements accurately yet politely?

[Katie803]

I'm curious as to what the protocol is for quoting a patient and "politely" documenting refusal, etc? For example, one of my previous nursing teachers said that she doesn't like to use "Pt refused" in her documentation because it sometimes makes the patient seem uncooperative or difficult. How do you document these things? For example, if a patient has constipation, would you put "Pt complains of constipation" or "Pt states he is constipated"? See what I'm getting at? I want to be as accurate as possible, after all it's my fanny on the line. But at the same time I want to be professional and don't want to make a pt look like he/she is just a pain when maybe at that particular time they are just a little stressed but perfectly pleasant otherwise. I figure if I read a chart where there is a whole lot of "pt complains" or "pt refuses" I might assume they are not a very pleasant person and I don't want to go in a room treading on eggshells when it really isn't necessary. Another thing I was wondering about is documenting family member statements or concerns, even if they aren't worded so nicely. Please provide a few examples of ways to document such things. Here's a couple more to preen over:

Pt complains-yay or nay?

Pt states "I hate you m*$&@(!" or Pt is verbally abusive of staff?

Pt refuses treatment-yay or nay?

Anything else you might think of would be helpful! Thanks in advance!

-Second clinical semester ADN/RN student

[MN-Nurse, ASN, RN]

No problem documenting exactly what the pt said in quotes when it gets the point across.

One of my favorite progress notes was from an RN who had endured an amazing amount of verbal abuse. She documented exactly what the patient said in her note, word for word.

It was awesome.

[Double-Helix, BSN, RN]

It always helps to provide the reason for the refusal. For example:

"Pt refused 0800 dose of colace due to loose stool this am." Sounds a lot better and is more informative then "Pt refused morning medication." It also gives a reason for the refusal- loose stools, rather than implying the patient was being uncoorperative.

Likewise:

"Pt refused morning bath, stating that the took a shower last night." Is much better than "Pt refused to get washed up this morning."

Also, consider the context of the statement/situation:

"Pt complained of pain 6/10 in surgical incision." is very acceptable. Pain is a legitimate complaint. However, "Pt complained coffee was cold" is not so legitimate and probably doesn't belong in the chart.

Pt complains: Yes, I used this wording. I think that "complains" implies a sense of urgency, whereas "states" does not. If I read "Pt states he is in pain." I feel like the patient might still be comfortable. However, "Pt complains of pain" sounds like the need for relief is greater.

Verbal abuse: Document in quotation marks exactly what the patient says. Leave out any subjective date, such as how you feel or how you think the patient was feeling. For example, don't say: "Pt appeared very angry and yelled and swore at me for what felt like ages." Instead, say "Nurse walked into pt's room at 1000 and pt immediately said with raised voice "X@%^!$ *&@&^$!"

Pt refuses treatment: It's fine to say that they refused something, just always ask the patient the reason why and document that as well. Also, even if they don't give a reason, document that you offered the treatment to the patient again in an hour or so. For example: "1200, Nurse went into pt's room and asked to change wound dressing. Pt refused at this time- did not offer reason. 1330, Nurse went into pt's room and asked to change wound dressing. Dressing was changed without incident. Wound appears...."

I hope that clears things up for you!

[elkpark]

I often used "declined," as in "Client declined offered XYZ" because I think it is a more accurate description of what actually occurred than "refused," esp. when the client is not angry and just doesn't want whatever it is.

Re: verbal abuse and profanity, I worked as a staff nurse in psych for many years, so I've had lots of experience with this. What I have always done is chart verbatim the first episode in a shift ("Client stated, "Get the !@#$ of my room, you !@#$ing !@#$%, and stay the !@#$ out my room or I'll !@#$ your !@#$%."), and then, for the remainder of the shift, just chart something like "Client cont. to be threatening and verbally abusive." Saves some time and writing/typing.

I've always used "complains" for everything/anything because it's standard medical usage and "c/o" is quick and easy to write or type. :)

[AgentBeast, MSN, RN]

I usually use the format

Patient complain of (complaint) stating "exactly what they said."

Or if it is something good I'll say something like Patient very happy with this nurses care stating "exactly what they said."

It's good practice to quote exactly what the patient says. Provided it's relevant.

[chulada77, ADN, BSN, MSN, APRN]

At our facility the subjective portion of our assessment is simply us putting quotations" around exactly what the patient stated. If he said "I'm constipated you m%^*&&$&^*" then that's what you quote. This statement not only tells you the problem but also the mental/psychological state that the patient may be in at that time. If you are aquanted with the patient prior you'll know if this type of demeanor is out of character for them which is a sign of many F&E problems, etc.

As for the "refusing" portion. If I offer some type of nursing interventions and the patient says he/she doesn't want to do that then I put that he refused interventions and I state what interventions I offered. Personally, I do this to protect my license and show that medical interventions were offered. The patient is the one who "refused" not you so don't feel bad about writing EXACTLY what is occurring. It could save your license someday.