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?
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.
and the sad thing about it they will firer a nurse rather than upset one of these Pt. because The patient pays pay. We are a liability to the hospital because the hospital has to pay us.
Specializes in neuro, ortho, peds, home, home cardiac.
A couple of things occur to me here. First, a musculoskeletal assessment documentation with a verbal report to the appropriate medical practitioner would have provided you more protection. Perhaps as important would have been multiple notations of your objective assessment of your patient's response to the event. It is much more useful to document the patient's posture, expression, animation, statements (using quotations), activity, et cetera than to attempt to interpret these parameters in the context of the event you described. In my experience, the documentation of these data may be the most under-used (but important) documentation by all health clinicians.
"There HAS to be a psych component that hasn't been diagnosed in him yet!"
This is exactly what I believe it is. He seem to be a med seeker, attention seeker, and possibly a sociopath from a psych perspective. This behavior could as well be documented for an additional diagnosis. You did nothing wrong, more so not when you made mention of it in your documentation. Keep up the good work.
We have a 'green sheet' for notes/requests specifically for the MD. That is the only additional document I would have done for this Pt. I would have noted the tremors and suggested to MD that Pt thought it should be evaluated.
You did nothing wrong and your charting will prove it.
I think this patient wanted you to help her commit fraud. It's one thing to ask that you report her "symptoms" to the doctor. It's another thing to ask you to put her "symptoms" in the chart in a certain way. Does she want disability? Worker's comp? I don't know why but that's what I first thought when reading your post.
Merlyn
852 Posts
and the sad thing about it they will firer a nurse rather than upset one of these Pt. because The patient pays pay. We are a liability to the hospital because the hospital has to pay us.