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?
