Is there a proper way to chart what a patient/resident says?

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SaoirseRN

650 Posts

If you put it in quotes, it has to be verbatim.

Pt states, "[day shift nurse] didn't give me my medicine all day, and he told the aides not to come in my room." This would leave the staff name out but still quote the patient.

I was taught the same thing. If a patient cusses me out, you bet I quote it in the chart.

Or:

The patient stated that the day shift nurse "didn't give me my medicine all day..."

Still verbatim, but without confusing brackets inside the quotations.

dudette10, MSN, RN

3,530 Posts

Specializes in Med/Surg, Academics.

Why chart that anyway, with or without the other nurse's name? Residents say a lot of things and, I assume, that LTC nurses don't chart every word.

ETA: I can't figure out what you were assessing that required that particular verbatim. Was it to show subjective evidence of agitation or altered mental status?

That's not to say that I haven't used negative verbatims in my charting, but they were always used for the reason above--to show subjective evidence for something else that I was assessing.

SaoirseRN

650 Posts

Why chart that anyway, with or without the other nurse's name? Residents say a lot of things and, I assume, that LTC nurses don't chart every word.

To show behavioral patterns. If it ever came to something legal, and the staff say "He always says that" but nobody charts it, and the resident or family insist that this isn't true, there is no paper trail to suggest otherwise. I ALWAYS chart when someone makes accusations or threats, no matter how innocuous they may seem, because it helps show a pattern if there is one.

BrandonLPN, LPN

3,358 Posts

If you want to document this particular behavior issue, you can simply chart "resident continues to make accusations against staff." A good rule of thumb is NOT to chart something that could be construed as incriminating against someone else. If you feel the pt *really* did not receive his meds, you should adress that nurse personally before doing anything else. Then, if you really need to, you can fill out an incident report or something. NEVER document what you described in the pts chart. Such comments should NEVER be a part of the permeant medical record. They belong in incident reports.

tex08

1 Post

Never chart your coworkers name! Refer to your coworkers by their credentials "RN, LPN, DON, ADON, Administrator" etc. When I worked in LTC, I did encourage nurses to document if the DON or other superior (including myself) was made aware of a serious situation because you never know when a lawsuit may arise and the only thing that will save your license is your charting. And I have personally witnessed situations where I know that the LPN told the DON about a situation but the LPN did not document that the DON was made aware...and the DON "did not recall" the nurse's conversation with her when the states investigation was being conducted. It came down to the LPNs word vs the DONs word. LPNs are a dime a dozen in LTC. It's hard to find and keep a good DON...always remember that.

Pattyrn1960

1 Post

As a new nurse .......... this is why they call it the practice of medicine and/or the practice of nursing. As people and nurses we aren't perfect; we are lifelong learners. Take it easy on yourself. I am sure you can let the other nurse know this was part of your learning curve. I think it is very admirable of you to seek out other nurses advice. I too was taught (31 years ago) never to put another professionals name in negative charting. On if someone else assisted or provided care you were unable to give. Good Luck and keep trolling in the deep water of nursing!!!

dudette10, MSN, RN

3,530 Posts

Specializes in Med/Surg, Academics.
To show behavioral patterns. If it ever came to something legal, and the staff say "He always says that" but nobody charts it, and the resident or family insist that this isn't true, there is no paper trail to suggest otherwise. I ALWAYS chart when someone makes accusations or threats, no matter how innocuous they may seem, because it helps show a pattern if there is one.

I can understand that. Thanks for your explanation. I just feel as if there could have been a different, less incriminating way to chart this accusation.

At any rate, I would hope that the other things the OP mentioned had also been charted prior, i.e. "It's your word against mine; I'll have your license!"

Document what a patient states objectively and accurately, and make sure it is free of bias or judgment. Quotations are appropriate; you just word it, "the client/patient stated, 'I'm not taking my medication today'", if the client refused medications, for example. Here's a good CNE on nursing documentation. You can view it for free, but you have to pay to receive credit. Document It Right: A Nurse's Guide to Charting | 60076 > Continuing Education Unit at Nurse.com

1 more thought: Make sure you document an intervention if you document such a bizarre assessment. My objective is always to document the nursing process as concisely as possible.

wooh, BSN, RN

1 Article; 4,383 Posts

Direct quotes, but don't name the names of staff. I love when pts and visitors start cursing and threatening. Makes charting so much more fun than the usual clicking the same thing over and over again. :)

Specializes in ER, progressive care.

Any time I chart what I patient says, I chart "Per patient" or "Patient stated." In your case, I would have charted "Patient stated the nurse didn't give me my medicine all day, and he told the aides not to come in my room." If a patient cusses me out, I was taught to chart verbatim with quotes.

Never chart your coworkers name! Refer to your coworkers by their credentials "RN, LPN, DON, ADON, Administrator" etc. When I worked in LTC, I did encourage nurses to document if the DON or other superior (including myself) was made aware of a serious situation because you never know when a lawsuit may arise and the only thing that will save your license is your charting. And I have personally witnessed situations where I know that the LPN told the DON about a situation but the LPN did not document that the DON was made aware...and the DON "did not recall" the nurse's conversation with her when the states investigation was being conducted. It came down to the LPNs word vs the DONs word. LPNs are a dime a dozen in LTC. It's hard to find and keep a good DON...always remember that.

I have an issue with this at work...in our computer charting system there is a section where you can chart "Report given to ____" and "Report received from ____." You type in the person's name and it pops up. Then in the nurses notes they will also chart "report given to Jill RN" or something like that. Some floors are taught to do that but I feel like it could be a possible liability issue? I don't know. When chart audits are done they can see who charted what and who put in orders, etc, which is fine. I just don't like having my name out there in the open glued to a patient's chart.

dudette10, MSN, RN

3,530 Posts

Specializes in Med/Surg, Academics.
more thought: Make sure you document an intervention if you document such a bizarre assessment. My objective is always to document the nursing process as concisely as possible.

This is a good point, and it applies to this situation. If the patient stated that the day nurse didn't give him his meds all day, what did the OP do about it? I mean, the statement is just hanging out there in the chart, and there is no documentation that the OP did anything the follow up? Was the MAR checked, was the resident's med cartridge checked, etc?

This is an example where a verbatim accusation against one nurse can lead to problems for the reporting nurse.

JailRN

333 Posts

Specializes in correctional, psych, ICU, CCU, ER.

"The truth, the whole truth and nothing but the truth". Sounds like you have more on your hands than an ugly, foul mouth pt. You have co-workers who 'yell at you'. I wouldn't put up with it. You were correct in your notes. It's not your job to write nurses notes to make your coworkers look good. Or to paraphrase. You write exactly what was said! All else is subjective. And I'd be in somebody's office filing paperwork on your charming coworker.

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