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

Nurses   (12,918 Views | 29 Replies)
by black_widow192 black_widow192 (New) New

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I am a fairly new nurse, and I am working my first job. Is there a proper way to chart what a resident says? I was taught in school to ALWAYS ALWAYS chart exactly what a patient/resident says no matter what it is. Tonight when I got to work a co-worker yelled at me for putting his name in my nurses note because it made him look bad. The only reason his name was in my nurses notes was because the resident stated "so & so didn't give me my medicine all day, and he told the aides not to come in my room." This resident is very paranoid, always yelling at the staff, saying things like "i'm gonna F**K you up" & "it's my word against yours, i'm gonna have your license." Was I wrong to chart exactly what she said? Was I wrong to put his name in my notes?

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TheCommuter has 10 years experience as a BSN, RN and specializes in Case mgmt., rehab, (CRRN), LTC & psych.

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How would you like it if a coworker charted a statement that made it appear that you had not administered the patient's medications (when you know you did)?

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casi has 3 years experience as a ASN, RN and specializes in LTC.

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I would chart it as:

Resident stated that evening shift nurse "didn't give me meds all day and told the aides not to come into my room."

I was taught not to use names in charting, unless you are mentioning family members.

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NRSKarenRN has 40 years experience as a BSN, RN and specializes in Vents, Telemetry, Home Care, Home infusion.

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Moved to General Nursing Discussion for our seasoned veteran's advice.

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SaoirseRN has 8+ years experience.

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In that situation I might have charted:

Resident stated that the staff "didn't give me my meds all day!"

In this way, you are still quoting the patient directly without naming staff members.

The only time I ever use another staff member's name in charting is if I am transferring a patient to another department, I would chart "verbal report given to Jill, RN 3rd floor."

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TheCommuter has 10 years experience as a BSN, RN and specializes in Case mgmt., rehab, (CRRN), LTC & psych.

2 Followers; 228 Articles; 27,607 Posts; 318,355 Profile Views

Threads merged.

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liveyourlife747 specializes in Home Health/PD.

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I agree. I would have wrote: resident states "my Meds werent given to me all day!"

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DSkelton711 has 25+ years experience and specializes in OB/GYN/Neonatal/Office/Geriatric.

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I would certainly put any quotes in context as well-such as body language, pacing, shaking fists, and that MAR was checked, prior nurse spoken to and verifies patient received medications, staff has noted signs of agitation, any other comments, not just the ones that seem to hang your co-worker. Is he cursing? Threatening to report everyone? Threatening to leave? We could be quoting all day long on some folks. I sometimes paraphrase with quotes put in: patient states that prior nurse "refused to give me my medication all day long". As you gain more experience you will find a style of charting that suits you while staying within legal boundaries, but isn't necessarily textbook.

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Meriwhen is a ASN, BSN, RN and specializes in Psych ICU, addictions.

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I'll paraphrase for the most part, but I always try to quote verbatim if a patient is threatening staff for any reason real or imagined. Yes, that includes profanities...I've written notes full of the 7 words you can't say on television, racial slurs, gibberish, etc., because that's exactly what the patient said (nor do I asterik (sp) or blank out parts of the word either). Keep in mind that I'm in psych, so we have to consider whether there's any real weight behind these threats...plus documentation helps if a Tarasoff/notification, legal hold, or other action is required.

I avoid putting in other staff names but will use their title (e.g, "patient yelled at LVN"). However names go in if I'm writing that they received report or that they did something for me that I didn't or couldn't do (e.g., "[male] patient searched for contraband by Dave, RN. Nothing was found").

In your case, I would have wrote, "Patient was complaining that staff did not give him his medication today as well as told other staff not to enter the room. Patient also made threatening statements to staff: "I'm gonna **** you up!' " And of course, chart body language, affect, etc., as well as what you did about the matter (if anything).

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nursecheryl specializes in inpatient hospice house.

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I agree with other posters that there may have been a better way to chart what the patient said without using another staff members name. I have come across the same situation as well and wouldn't have written the persons name. Sort of like when you write a incident report you don't put that in your charting.

Edited by nursecheryl
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BrandonLPN has 5 years experience as a LPN.

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I would have been angry, too. Now you know better. I have a resident who always accuses the CNAs of stealing her money. As in daily. Of course I don't chart that, paraphrasing or not. We chart by exception. Crazy, demented old people saying crazy, demented stuff is *not* exceptional.

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SHGR is a MSN, RN, CNS and specializes in nursing education.

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I agree. I would have wrote: resident states "my Meds werent given to me all day!"

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.

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