LPN asks: Is this DON's admonishment inappropriate?

Dear Nurse Beth Advice Column - The following letter submitted anonymously in search for answers. Join the conversation!

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Dear Nurse Beth,

I work for a registry and have been an LPN since 2011.

This is a recent incident that I would like to share. It's regarding a progress note entered into a resident's EMR. Moving forward I would like to mention my post will be a HIPAA complaint.

Last week I was assigned to the behavioral unit for 3 consecutive nights. 2 out of the 3 nights, I received report from the same nurse. Each time I was advised to frequently keep an eye on a specific male resident who had been getting in the personal space of female residents and asking them for kisses etc.

This past Sunday, I entered a note in the residence chart and is exactly what I said:

RESIDENT OBSERVED IN HIS ROOM WITH A FEMALE RESIDENT HAVING WHAT APPEARED TO BE AN INTIMATE CONVERSATION SINCE THE RESIDENT WAS HOLDING HER ARM. THE NURSE OFFERED TO ASSIST THE FEMALE RESIDENT TO HER ROOM AND HELP HER GET READY FOR BED. THE RESIDENT OF THE ROOM BECAME VISIBLY ANGRY AND YELLED, "STAY OUT OF IT!" THE FEMALE WAS COMPLIANT AND MADE HER WAY OUT WITHOUT INCIDENT.

The following day I received a call from the DON and she was not happy. She said, she doesn't want to step on my toes but this is something we do not include in the resident's chart. It makes the facility look at fault etc. She said do not use words like intimate. The conversation ended with her telling me that she and the administrator will decide if I need to make an addendum to the note.

I picked up a couple of shifts at the facility on the behavioral unit and as I am reviewing progress notes, I see that the DON entered an addendum to my note. This is exactly what she wrote but I removed names to protect identities.

FOR CLARIFICATION PURPOSES: TODAY WRITER SPOKE WITH JANE DOE REGISTRY NURSE ON DUTY FOR 7/12 6P-6A FOR CLARIFICATION PURPOSES OF NOTE WRITTEN 7/13/22 AT 12:29A. JANE (NURSE) STATED THAT SHE OBSERVED FEMALE RESIDENT IN MR. ***ROOM AND THEY (THE TWO RESIDENTS) WERE HAVING A CONVERSATION IN A NORMAL TONE AND IT WAS NOTED THAT MR. *** WAS HOLDING FEMALE RESIDENT ARM. JANE(NURSE) COULD NOT SPECIFY WHAT THE CONVERSATION WAS PERTAINING TOO BUT DID NOTE THAT THE FEMALE RESIDENT WAS NOT IN DISTRESS BECAUSE OF HER MANNERISMS, JANE (NURSE) IMMEDIATELY SEPERATED THE TWO RESIDENTS BY OFFERING TO ASSIST FEMALE RESIDENT TO HER ROOM BECAUSE IT WAS BED TIME AND THAT IS WHEN MR. *** BECAME UPSET. FEMALE RESIDENT WAS COOPERATIVE AND CALM. JANE (NURSE) STATED THAT ENGLISH IS HER SECOND LANGUAGE AND THAT THE TERM "INTIMATE" MEANT MORE SO "PRIVATE 1:1 CONVERSATION". JANE DOE (NURSE) IS REGISTRY AND WAS UNCERTAIN WHEN SHE WOULD BE IN THE COMMUNITY AGAIN). **** RN DON.

I just want to know your thoughts and get another nurses' perspective. I do not think this was appropriate for her to do. Thank you so much.

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Specializes in Tele, ICU, Staff Development.

DON Charting Defensively

It's clear your DON is charting defensively and that's because it's her job to minimize risk towards the facility. She is doing her job.

Objective

Nurses' charting should be objective, and measurable when possible. If 2 nurses document the same event, it should essentially be the same, without opinion or hearsay. Document what you see and not what you interpret. 

Be aware of subjective and emotionally laden words. Using the word "intimate" is a subjective description. You would not be able to defend that description in court. The only 2 people who know the nature of the conversation are the 2 people involved.

Documentation should be relevant. Document to facility policy. It's important to be well versed in each facility's policies and to document within that context. It makes a difference. For example:

  • If the unit has a no touching policy, then document "Patient A observed touching Patient B's arm. Patient A redirected. No distress noted by Patient B."
  • If the unit does not have a no touching policy, then document "social with peers".

Here's a tip: Long ago, I began reading doctor's notes after they visited my patients. Why? To learn more about my patients' diagnosis and treatment. In so doing, I noticed how very clear, concise and analytical doctors' documentation is. Even words like "moderate" and "severe" have agreed upon meanings and are not subjective.

Anticipation

If you had not been warned that this patient behaved inappropriately towards female patients, do you think you still would have interpreted the conversation as intimate?

Not saying it should not have been included in report. In this case, it's important behavioral information and was correctly included in report.

Unfortunately, hearing reports of negative behavior can result in us unconsciously expecting and looking for behaviors to confirm what we heard. Sometimes that means anticipating an unpleasant experience. More than once I've received a subjective report, saying that a patient was demanding, for example, and then gone on to have a completely different experience during my shift.

It can also be hard to not label people or paint them with one brush. Black and white thinking is easier and more comfortable than ambiguity.

Aim for high quality documentation. As the ANA Principles of Documentation state,  be accurate, timely, and valid.

High quality documentation protects both you and your facility.

Best wishes,

Nurse Beth

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