Doctor upset by charting

[LalaRN9000]

I work in mental health and sometimes distraught parents have unreasonable demands and expectations. Obviously this isn't a surprise when you're a nurse but I am just curious what other nurses would do in this situation.

My co-worker was talking to a parent who was pretty upset and she charted what the mom was saying. This included the parent saying that the doctor "must smoking something." The doctor ended up coming down to talk to her. He demanded that she take that statement out but the note was final. He told her to never chart things like that. It must have gotten heated because later she came out of his office in tears. Telling someone not to chart something seems pretty ridiculous. I am not really sure why the doctor acted that way, he is usually a pretty chill guy.

So would you document verbatim? I would.

[Tenebrae, BSN, RN]

I had a similar sort of situation. I wrote a patient note and when I came back the next day I found that the charge nurse had crossed out part of my note referring to time of PRN medication admin, (it was about 10 minutes out) and written in what she perceived was the correct time. I was quite blunt and said "Do not change my documentation please. If you disagree with what I have written or you wish to clarify a point, then please ask me to write an ammendment to clarify or write it yourself, but it is not appropriate to change another nurses documentation"

In the case of the doctor, he cant dictate what you write, if hes going to be a dick about it, put a single line through the part of the note that annoyed him sign and date it and put an amendment along the lines of 'Above note removed as per conversation with of Dr Dickhead at Day, date and time"

[Al Kalosis]

You make some pretty significant assumptions of someone who isn't here to defend himself. If you truly consider it narcissistic to not want a statement connecting you to impaired practice... I don't even know what to say about that.

Would you truly feel peachy keen if you read in someone else's note: "Pt's mother states, 'Al Kalosis is such an idiot, he MUST be smoking something.'?" If this mother sued, do you honestly believe that a standing-to-profit attorneys would look at the notes, read the above statement and say, "oh I'm sure this mom is just being irrational; Al Kalosis is a highly competent nurse?"

The only assumption I've made is that the OP's statement is accurate. The physician's disapproval of the quotation is reasonable. There are valid concerns regarding the use of direct quotes by the nurse, as you have described. However, the physician "demanded" (according to the OP) that this information, observed and reported by the nurse, be removed from a legal document. I stand by my accusations.

[TruvyNurse]

I chart word for word. Can't accuse me of leaving anything to question

[JKL33]

Expressing one's concern and demanding (according to the OP) that information be removed from a legal document are not in the same ballpark.

So true. Too bad the OP wasn't there and chose that word ("demand") herself...my guess is that verbiage was chosen mostly due to the fact that someone cried.

[Dadof2RN2Be]

I think quoting and accurately charting any situation is important. But we must make sure we are doing it within reason, and not quoting every single thing. I think we need to also remember that the physician isn't the one that will be called to court or questioned about your charting, you will be if things escalate that far. I believe that if more detailed (within reason) charting is used, it's easier to answer questions in relation to a patient or experience while lax charting can leave space for speculation and doubt when it comes to legal issues.

[canoehead, BSN, RN]

We don't have enough information about this specific situation. In general though, the doc doesn't get an opinion on what the nurse charts, unless it is inaccurate. If the visitor states the doctor is a bullrider, and its charted, it doesn't make a lick of difference that the doctor hates cattle, and couldn't even get up on a merrygoround without a boost and two coaches. What she said is charted accurately.

I've had docs remove monitor strips from the chart because they didn't like what was on them. I've had docs say "make sure you chart xxx happened this way" or "you charted xxx so now I have to order y even though they don't need it." That's crap. They can chart their own findings and interpretation, but they can't dictate to others.

[CaffeinePOQ4HPRN, BSN, MSN, LPN, RN]

Charting verbatim is appropriate, creates context, and helps build a record of history. For example, if there are issues with family dynamics or legitimate concerns of an HCP, consistent documentation helps build a case in defence. I hope you added more to the charting than the one-off comment though.