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?
but that type of note demonstrates that pt was asked...
whereas "no complaints voiced", puts pt in proactive position.
we are the ones who are supposed to be actively assessing, not the pt.
leslie
Yeah but how often do we do things because the pt tells us I have N, it hurts when I pee, etc etc because we ask if there is something that we ask. IDK I see how both can work and both can be interpreted in different ways.
"No Complaints Voiced" means just that. As to how much credence I give it, that depends.
I usually do a head to toe at beginning of my shift and chart accordingly and this is what I base my shift on, using the previous report and notes as reference only, but not as my basis.
I ask if pt has pain, etc. If patient denies pain/needs and no s/s distress, I chart, "pt denies pain or discomfort. Denies needs at this time. No s/s distress noted."
I think previous charting has no bearing on what I may find at the beginning of my shift, as my patient condition may change or they may feel more comfortable telling me what they failed to tell the previous nurse ("she seemed so busy I felt bad bothering her" or "I forgot" or whatever other reason).
As to my sig, my sig is a scribble, followed by RN and my employee ID. That way, anyone can find me, regardless. I will not "write out" my name because that is not my legal signature as shown on my driver's license. Anyone needing to find me can do so by my employee ID or eCharting, which shows my complete credentials. Also, reviewing the chart will show them my sig, ID#, credentials at the beginning of the shift and again at the end of the shift.
Specializes in Gerontology, Med surg, Home Health.
I was taught to write "denies pain" as opposed to "no complaints of pain". In the first case, it's plain that the questIon was asked. The second sentence leaves a question....did they have pain but didn't want to complain?
I get what it means. However for an A&Ox4 person I use "No needs voiced. No complaints of any pain/discomfort at this time"and the reason why I know this is b/c I ask. If they are confused I'll put "resp even and unlabored, skin w/d, easy to arouse, no distress noted"
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.
I agree. You are never going to be able to chart everything, but that is why "WNL" or "within defined limits" is an option for the charting. Plus, it is always better to say "denies ____" (chest pain, for example).
I once worked with a nurse who would always chart "all safety measures provided." Really? What are "all" safety measures? Full siderails? Bed alarm? Are "all" safety measured different for a pt with demetia vs. a pt who is A&Ox3? Point is, these blanket statements are convenient but very vague, and they don't provide much info to a provider/another nurse reading the note, and they won't do much to protect you in court.
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That Guy, BSN, RN, EMT-B
3,421 Posts
Yeah but how often do we do things because the pt tells us I have N, it hurts when I pee, etc etc because we ask if there is something that we ask. IDK I see how both can work and both can be interpreted in different ways.