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

[shhhh]

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?

[DixieRedHead, ASN, RN]

They are nursing notes. Not patient notes. The nurse does the charting. You chart what you see, as YOU would describe it. Let the patient chart what, where, and how he pleases.

[CrunchRN, ADN, RN]

I would have documented "patient is a spaz"

Yeah, I know, I'm cruel.

damned if you do and damned if you don't - sheesh.

[Meriwhen, ASN, BSN, MSN, RN]

sounds like you work at a planetree (or planetree wanna-be) hospital :/

nothing against planetree: i'm for a lot of its aims and think it can be beneficial. but the whole open-chart with patients critiquing what you chart and trying to dictate to you what to chart business is imo too much.

[Scarlette Wings]

i think you did the right thing. it is hard to chart honestly and truthfully with someone watching and judging everything we document. your documentation is yours, it is your evaluation and your assessment based on your education and level of experience.

[Piglet08]

I would also document - objectively - his statement instructing you to chart in a specific way.

[psu_213, BSN, RN]

Just chart what was said by the pt and your objective findings:

'Pt. states "I just had a pseudoseizure." When blankets taken off pt's legs, found pt's legs shaking for approximately 3 seconds. After shaking stopped, pt was lying on stretcher A&Ox3, moves all extremeites well, follows commands. No shaking in any other extremities.'

Something to that effect...that way, what the pt "wants" you to say is there, but it is in quotation marks--people will know these are his words not yours. Also your objective findings are there, it is pretty obviously the pt is not postictal. At this point, the doctor can read the notes and further investigate the situtation if he sees fit. (Also, the pt may not have said 'pseudosezure' but it seems like something this type of pt would say )

[Nurse Fee Fee]

That is my question to....MomRN

[Wishinonastar, BSN]

I think he was concerned and wanted his doc made aware- you did not do that. When a patient asks me to report something, I report it. Maybe it did not seem significant to you, but involuntary tremors is a frightening thing to have and he was afraid. He felt his fear was being brushed off and that made him angry. This is why patients sue. They feel their needs are not being met.

I think I would make it clear to whomever you need to talk with about this that you did not realize how concerned he was about this symptom, you charted it and planned to observe. If you had realized his concern you would have done more. Otherwise it simply appears that you ignored his distress.

[Merlyn]

I can be psycho...I mean psychic in this sort of situation. Let me see...The patient advocate never read the chart. Am I right?

My Lakota sprite guide tatanka lyotake told me, and Sitting Bull is never wrong.

[NicuGal, MSN, RN]

How do you know another nurse told him this? Is this something he reported to the ombudsman? If so, take it with a grain of salt. There are just some patients that are like that.

[catlover5]

I learned the hard way by a similar situation......only the hypochondriac patient had been a nurse-at the same hospital-before getting hooked on drugs and becoming a "frequent flyer." I should have known during report when other nurses were saying "don't give *that patient* back to me, I had *pt* last month," or "No way, I had *pt* last night." Basically I was told what to do and when to do it. And being an LPN made it worse for me. Needless to say, before morning report, this pt had told the unit manager that I didn't lay a hand on *pt* and pain meds were consistently late. Not true.

SO, after report, I'm in the office being accused of false documentation!! This patient, as a nurse and employee of this hospital, was well-liked back in the day and the nursing director was believing the patient. Thankfully the charge nurse had my back and the "investigation" was closed. And this pt requested NOT to have an LPN for the remainder of the stay "because they are too limited with what they can do." Pt had a Dilaudid PCA with a hearty dose, but wasn't getting the Phenergan fast enough, or a big enough dose to suit the pt. Of course that was all my fault ???

After that, it was suggested by some older nurses that when a patient is being difficult or sketchy, make notes on everything, what the patients is demanding/requesting/complaining...what the charge nurse says when notified...... Taking a second to chart on the occasional "problem patient" has definitely been worth it!!

[lamazeteacher]

MUCH ADO ABOUT NOTHING.......

It must have been a very slow day for the Pt. Advocate!

You made an observation, you charted it, and that was all that was needed. No "report" was indicated! Patients are allowed to see their charts so they know what has been done, a critique of it is not their purvue. If they choose to object to something more significant, they can contact their attorney (who is probably sick of their whining, too).

Patients need to be given some power about their care, but this is not something that involved choices for this pt. He's just a whiner who needs to feel important, and the Pt. Advocate wanted to validate their existance and didn't care about employee morale.