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I didn't chart like a patient wanted me to...?

Nurses   (8,216 Views | 30 Replies)
by shhhh shhhh Member

shhhh has 8 years experience and specializes in ICU, ED, Trauma, Transplant.

4,237 Profile Views; 88 Posts

I witnessed my patient have "tremulous" legs for about three seconds. I had some serious doubts that it was an actual tremor; it happened when I pulled his blanket off his legs, and I thought at the time that his legs were shaking that little bit because he became cold. He acted concerned about it, but also said that this happens every once in a while. He asked that I document it so his primary doctor would know that it happened.

If I do remember correctly, I did document objectively, something like, "brief shaking noted in BLE when blanket removed, patient states this was involuntary; will continue to monitor" or something like that in my hourly assessment flowsheet when it had happened. I asked him to please let me know if it happened again, but he never said anything to me about another episode. During the 12 hr shift I took care of him, he was a bit needy and needed a lot of emotional reassurance, and struck me as the type of person who typically makes a mountain out of a molehill.

Imagine my surprise when I receive a email from our hospital patient advocate services office. The patient advocate told me that he had wanted to talk to someone in their office about me. Apparently, he was told by the nurses who later took care of him on the med/surg floor he transferred to that I never did "write a report" like he told me to.

In our charting at my hospital, nurses chart by exception within a documentation flowsheet and have the option of writing specific comments, which I had done. We write only two type of narrative notes: care plan notes , and significant event notes (any invasive procedures, CODES, blood transfusion reactions, seizures, etc. You know, ACTUAL significant events!)

He basically wants me to write a significant event note about his legs shaking for three seconds. I think it's inappropriate and a bit ridiculous to write a significant event note about that. I really do think my comment about it within my assessment flowsheet is adequate.

I plan on talking about this with my manager, but I would appreciate any feedback on what any of you would do in a situation like this. I've never had my documentation questioned before, and while I can understand this patient's concern, I'm a little angry that he's basically demanding and involving the patient advocate office over this, trying to get me to endorse something I don't feel 100% certain is a legitimate health issue. Am I being way off base here?

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1 Follower; 1,021 Posts; 16,667 Profile Views

I think you did what you needed, you wrote a note about the shaking like he asked. The patient does not get to dictate the notes that you write. If the patient is super concerned about it they can speak with the DR about it. After all, you only witnessed one incident of 3 seconds. I think you did fine. My opinion may change if In know what he was in for. If he had some kind of neuro surgery or a history of neuro disorders I would be concerned. Any numbness or tingling?

I guess it is hard to say without knowing why he was hospitalized.

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KelRN215 has 10 years experience as a BSN, RN and specializes in Pedi.

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Objective findings are just that- objective. You witnessed his legs shaking for 3 seconds and you documented it. Nursing documentation is based on nursing assessment, not what the patient wants you to document. I can't even believe hospitals waste their time with this stupid sh&t. If the patient was really that concerned, I agree, they should address it with the MD when they do their daily rounds.

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nursel56 has 25+ years experience and specializes in Peds/outpatient FP,derm,allergy/private duty.

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Go ask the nurses who told the man you didn't write the report about to show you all their reports for things of similar significance. I guess it would've been too much to expect them to explain how nurses typically document things at your facility. It was kind of crummy of them to leave him with the impression you didn't do something you were supposed to do.

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1 Follower; 1,021 Posts; 16,667 Profile Views

I would be mad at the other nurse who told the patient you did not document it. Because really, you did. Did the other nurse document it? What did they write?

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MomRN0913 specializes in ICU.

1,131 Posts; 19,648 Profile Views

Sorry, but what *** is happening to this profession?

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shhhh has 8 years experience and specializes in ICU, ED, Trauma, Transplant.

88 Posts; 4,237 Profile Views

Thanks everyone! I feel better knowing you all agree with me. I've never been "in trouble" with the patient advocate office before and I'm glad you all support my view on the matter. The more I think about it, the more annoyed I get. And the more I think, the more I'm certain his legs were shaking from him being cold.

I guess it is hard to say without knowing why he was hospitalized.

He was admitted for pain control after breaking a couple ribs. Should be easy enough to deal with, but his anxiety, neediness, control issues and constant need for reassurance made me quite busy. There HAS to be a psych component that hasn't been diagnosed in him yet!

It was kind of crummy of them to leave him with the impression you didn't do something you were supposed to do.

And THANK YOU!! From the language in the email I got, it sounded like all the nurses who followed me pretty much threw me under the bus in this situation. This particular unit he transferred to has a reputation of that sort of behavior, so I guess I shouldn't be surprised. Definitely crummy.

Here's a thought: he was in the hospital for 3 days... so why is my documentation so important to him? My guess is that he doesn't actually have a tremor like he thinks and I was the only one who saw anything remotely close to a "tremor", so he's clutching to that thinking if someone else saw a tremor, then it must be real and his doctor should finally believe him now? If he does have a legitimate issue, then surely I wasn't the only one who might have seen anything odd in 3 whole days, right? Someone else would have documented a tremor and I wouldn't be having to worry about this. Not that I saw anything odd or anything; I really think I just saw a hypochondriac patient get chilly. :/

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11,191 Posts; 54,453 Profile Views

I really think I just saw a hypochondriac patient get chilly. :/

this whole thing is just plain nuts.

pt advocacy shouldn't have ever gotten involved, except maybe to give you a heads up re pt concerns.

other nurses should have educated pt about nurse's notes...

and that they are written per hospital's p&p...and not pt's request.

if i was going to write a note about this pt, i would have jotted about PT's concern of tremors, and "psych eval ordered."

psych eval is the only intervention that would have warranted a nurse's note.:cool:

leslie

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BlueDevil,DNP has 25 years experience as a DNP, RN and specializes in FNP, ONP.

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Ridiculous. Your charting is sufficient. Move on.

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Perpetual Student has 4+ years experience and specializes in PACU.

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Just point out your documentation to anyone giving you a hard time. It sounds like you did a fine job of documenting that horrible concern.

I must say that I'm surprised you didn't call a code, though. Clearly he was on the verge of dying from shivering increasing his oxygen demand. Should've hooked up the Bair Hugger and given him some Demerol to ease those intractable rigors.:bugeyes:

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Been there,done that has 33 years experience as a ASN, RN.

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The patient is a borderline personality. Whatever you co-workers "reported" about your charting is both unprofessional and not required.

This 'Advocate" needs a lesson regarding their limits in the patient care areas.

I would file a grievance and cover my ass... borderlines will NOT let it go.

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MomRN0913 specializes in ICU.

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I would have documented "patient is a spaz"

Yeah, I know, I'm cruel.

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