Just wondering......

If I find it pertinent to the day's shift, I write it in the manner Kate indicated. I would otherwise write a communication note, still watching my language and tone, if I wanted to communicate and document the situation outside of the particular shift happenings. This would be in a situation where I want to document what went on without divulging the documentation to the client and client family. You have to realize that some families copy the field copy of the nursing notes for their own use, including law suits. A communication note to the employer is not so easy for them to use against you. If I want to discuss the matter freely, and it is important enough, I will call and speak to the nursing supervisor and/or DOCS directly (I also follow up with a communication note to document my phone con with the manager I spoke to).

Honest answer- context. Some people are angry with the agency and rude to the staff more or less on a continuous basis. They've already called the agency multiple times with the same complaints. There wouldn't be any point to charting that, because it would be a normal part of their daily routine. When they start to complain about the agency I tell them I have no control over that and hand them the phone or offer to call in for them.

However, if there was an escalation, ie the patient is going to call the Hotline to complain, the family member becomes abusive or threatens, the patient tells you to get out of their house, or ask you to call the police or 911, yes-yes-yes. You inform your agency and document your heart out. All these things have actually happened!!!

Even then, I would describe objectively as much as possible and shy away from using words such as "rude" or "angry". You can quote them, and say what type of tone and body language they are using.

On the other hand, if the sweet little old lady you've known for months suddenly begins to become rude or paranoid or whatever- you will document that and maybe insist she be checked because it means something bad may be going on even though when she is rude she is actually less rude than the other family on a normal day.

Hope this makes at least a little sense! Gotta love home health!