"No Complaints Voiced"??

[Hooch]

We are all familiar with the standards of proper documentation that say's that any matter that affects patient care needs to be documented, and the presumption in cases of litigation that "If it isn't documented it isn't done"!

Progress notes would tend to state facts like vital signs, levels of consciousness, sat levels, significant changes in the patients condition, and plans for diagnostics, procedures and discharge etc. This is a statement of facts based on your assessment and observation.

However, sometimes in the documentation there is a singular reference to "No Complaints Voiced" and no explanation as to what it actually refers to.

What does "No Complaints Voiced" actually mean? Is this a subjective observation or opinion, rather than it being a determined fact following an assessment? I would think that it can cover a multitude in terms of its actual meaning - from they didn't voice any complaints about having pain, elimination, mobilizing to breathing, to complaints about standards of care. But if a patient doesn't voice a complaint does that actually mean that they don't have any complaint?

Should you document a blanket statement that the patient didn't voice any complaints if you didn't ask or give the patient the opportunity to voice a complaint?

Are there certain groups who just don't like to complain about anything - like a generational thing - the older population being one case in point? If a patient had a problem with the standards of care they were receiving while they are still in hospital, how many are likely to complain while they are still in hospital or would they lodge a complaint post discharge?

Thoughts....

Another question, when you sign documentation do you actually print your name in full or is it a signature akin to a scribble?

[TheCommuter, BSN, RN]

When dealing with AOx4 people, I usually document that the patient is able to make his/her needs known, that (s)he voices no complaints, that the call light is within reach, and that the patient has been instructed to call as needed.

If the patient is unable to make his/her needs known, I'll document that all needs are being anticipated and that no s/s of acute distress are observed at this time.

"No complaints voiced" can cover an array of issues. To me, it means that the patient is not voicing acute symptoms: pain, blurred vision, numbness, headache, nausea, difficulty breathing, palpitations, and so forth.

[merlee]

This is an excellent question. Just because someone doesn't say it to you does not necessarily mean that have no complaints. Maybe the complaint involves you!

And we were taught that our signature had to be legible. One hospital I worked at made the docs sign the charts with their name and pager number! If you couldn't read their actual name at least you knew what number to call!

[carolmaccas66, BSN, RN]

You are reading too much into this statement. No complaints voiced means exactly that - it doesn't mean anything else.

I always say 'Nil concerns/complaints to time of report'. Also down under, we must print our name and designation (I put my agency as well), and sign as well.

[Hooch]

You are reading too much into this statement. No complaints voiced means exactly that - it doesn't mean anything else.

I always say 'Nil concerns/complaints to time of report'. Also down under, we must print our name and designation (I put my agency as well), and sign as well.

And when you document "Nil concerns/complaints to time of report" what process of assessment do you undertake to reach that conclusion out of interest? Should there not be more detail as to what you're referring to?

[gardentulip27]

would be great if all providers put the pager number and printed under signature. Another way to deal with voiced no complaints is to quote the patient. "I am fine and don't need anything now". They say it so writing it says it all in SOAP.

[CT Pixie, BSN, RN]

When dealing with AOx4 people, I usually document that the patient is able to make his/her needs known, that (s)he voices no complaints, that the call light is within reach, and that the patient has been instructed to call as needed.

If the patient is unable to make his/her needs known, I'll document that all needs are being anticipated and that no s/s of acute distress are observed at this time.

"No complaints voiced" can cover an array of issues. To me, it means that the patient is not voicing acute symptoms: pain, blurred vision, numbness, headache, nausea, difficulty breathing, palpitations, and so forth.

Ditto this. With my AOx4, I write the same as Thecommuter. I also will chart that resident displayed no non-verbal cues to pain or discomfort (or that they offered no complaints but such and such non verbal was noticed). many of the older generation are stoic and will deny pain/discomfort etc even when they are, but they may give off non-verbal cues to it. I put that blurb about non-verbal cues to alert whoever is reading that I was given no verbal complaints but that I also did/did not note any non-verbal cues the resident could have displayed. I chart pretty much the same for my non-verbal and/or non AOx4 resients.

When I put no complaints offered it means just that, the resident voice/displayed no complaints, needs, wants.

We are set up for computer charting so I don't 'sign' my name per se. Although, when I do have to sign my name (pen to paper) I sign my name with my title legibly but in script , not printed.

[Altra, BSN, RN]

I agree with the poster who said that you're reading too much into this.

1. "Complaint" is being used in the medical sense; i.e., the patient's "chief complaint" meaning presenting s/s, or "c/o - complains of - abdominal pain".

2. "Voices no complaints" is one way of phrasing that an alert, oriented, communicative patient has no needs at this time. Documentation must include objective data - VS, etc. - but it can also be more than that. I'll pull out the old school phrase used before computer charting: "paint the picture of the patient". It goes without saying that "voices no complaints" is not appropriate if the patient is nonverbal or has some altered mental status that would interfere with the ability to communicate needs.

[xtxrn, ASN, RN]

If no complaints are offered, why bring it up at all?

"No complaints offered" could mean he didn't mention that he thought the wallpaper was butt ugly. Too vague. Won't protect anybody in a courtroom or deposition.

Specifics matter. Assumptions of "everything is fine because he didn't whine" can be risky imo.

[RanieRN, MSN, RN]

I'm the same as TheCommunter and CT Pixie.

If they're A&O and would have been able to tell me if they had complaints, I'll document "voiced no complaints". If they're not able to tell me, I'll document something like "no apparent distress noted; lscta, +bsx4" etc.

As far as signing, it should be written full signature with credentials--but there's quite a few of my co-workers who don't include RN or LPN. I don't quite understand that though, you worked your butt off to be able to do just that, why aren't you?

[One1, BSN, RN]

If it is regarding pain, I will note 0/10 for pain and write in the pain comment box "Pt states he/she has no pain at this time". If I ask them about (e.g.) resp complaints and they have none then I will type in the resp section comment box "Pt states he/she has no SOB or other resp complaints." A generalized no-complaints seems to cover a bit too much in my opinion. Either way, I always include "pt states" because it shows that we actually inquired.

[Always_Learning, BSN, RN]

Yup...if the patient is A&Ox4, then "no complaints voiced" is pretty straightforward. If, however, there is some sort of deficit, I try to be a little more specific: e.g. if the patient has a verbal deficit, "Patient shakes head "no" when asked if in pain."