To quote or not to quote...

[themoreyouknow]

Our director is now writing people up for using quotations in their documentation. She states it is a red flag for a lawsuit.

I thought that when you had a non-compliant patient or a pt who refuses treatment, their refusal should be documented in their own words. (The same goes for an unruly patient.)

For example:

You walk into the room to do a fundal check on a mom who has delivered lady partslly. The husband stands up and yells "If you're coming in to push on her stomach, you can forget it. It makes her cry and it hurts and nobody is going to hurt her while I'm here!" You explain that fundal checks are done to be sure the uterus is firm. A soft uterus can lead to hemorrhage. He says "You nurses think you know everything. You can just get OUT because it isn't going to happen!"

My director says we shouldn't document what the husband said in quotes because it sets the hospital up for a lawsuit AND because "the patient didn't actually refuse." She states we should write "Husband non-compliant with fundal checks". How can he be non-compliant when he doesn't have the fundus???

Those who use quotations are being written up.

Does your facility have a policy against quotations? What have you been taught to do?

Does anyone know of any professional organization that says to use quotations? (ANA, etc)

[caliotter3]

I was taught to use quotes as much as possible. I don't see how it sets the institution up for lawsuits. After all, wouldn't the plaintiffs have to be hanging around pouring over every word in the charts looking for their lawsuit material? Since when does that occur?

[brownbook]

Yes you should use quotes in patient charting, However mostly this deals with o basic patient care. An angry family confrontation is a completely different situation!

Pt. complains of pain 8/10, 2 mg morphine given IV, pt. states "I feel much better, the pain is gone."

I think you have an entirely different issue with angry family members? I can't say yes or no, right or wrong, that it is appropriate to quote family members in your charting. It is possible that quoting angry family members does NOT

However your director is absolutely wrong in writing people up for using quotes from the patients.

[brownbook]

Sorry I hit the enter key. I didn't finish my sentence. Quoting family members may and should NOT prevent you from giving the patient the care they need. You cannot NOT massage a fundus because you quoted that the husband was verbally aggressive. You still must massage the fundus (unless you quote that the PATIENT was verbally aggressive and refused treatment.) If that happened you would be notifying the doctor.

[n87934]

I was taught not to document negatives about the patient in the chart because people who perceive that they are being personally attacked may get angry and be more likely to sue.

I have had numerous challenges made over the years as to the necessity of doing something. I have found that educating the patient and/or family in an empathetic manner as to the rationale for what is being done goes a long way toward the patient being cooperative, the family being happy, and my being able to get my job done.

As for your above situation, wouldn't it be great to have been able to document:

Husband at bedside and expressing concerns about the need for certain assessments. Provided education to the husband and the patient on the necessity of assessments and they expressed understanding and allowed assessment to proceed.

[himilayaneyes]

I was told by my managers to quote the patient as accurately as possible in situations like that.

[themoreyouknow]

I was taught not to document negatives about the patient in the chart because people who perceive that they are being personally attacked may get angry and be more likely to sue.

I have had numerous challenges made over the years as to the necessity of doing something. I have found that educating the patient and/or family in an empathetic manner as to the rationale for what is being done goes a long way toward the patient being cooperative, the family being happy, and my being able to get my job done.

As for your above situation, wouldn't it be great to have been able to document:

Yes. An in a perfect world...

There are patients out there that aren't nice. There are family members out there that are verbally abusive to the staff.

I do not think "Pt. removed fetal monitor. Refusing to wear it. Explained the importance of monitoring fetal heart rate. Pt still refuses." says the same thing as "Pt removed fetal monitor. Refusing to wear it. States "This ******* thing itches and there is no way I am putting it back on." Explained importance of monitoring fetal heart rate. Pt states "My kid aint gonna ******* die because I won't wear your stupid belt. I've kept him alive this whole time, so obviously I know what I'm doing!"

Sometimes, I feel there is a need to convey the patient's attitude along with their actions. The only way to do that accurately is to use their own words.

[caliotter3]

One of the reasons for using quotes is your last statement in the previous post.

[RN_2012, BSN, RN]

Maybe this is a stupid question as I am still a student. Why aren't you asking the wife if she doesn't want the check or not? Then you can document that the patient refused the assessment.

Our director is now writing people up for using quotations in their documentation. She states it is a red flag for a lawsuit.

I thought that when you had a non-compliant patient or a pt who refuses treatment, their refusal should be documented in their own words. (The same goes for an unruly patient.)

For example:

You walk into the room to do a fundal check on a mom who has delivered lady partslly. The husband stands up and yells "If you're coming in to push on her stomach, you can forget it. It makes her cry and it hurts and nobody is going to hurt her while I'm here!" You explain that fundal checks are done to be sure the uterus is firm. A soft uterus can lead to hemorrhage. He says "You nurses think you know everything. You can just get OUT because it isn't going to happen!"

My director says we shouldn't document what the husband said in quotes because it sets the hospital up for a lawsuit AND because "the patient didn't actually refuse." She states we should write "Husband non-compliant with fundal checks". How can he be non-compliant when he doesn't have the fundus???

Those who use quotations are being written up.

Does your facility have a policy against quotations? What have you been taught to do?

Does anyone know of any professional organization that says to use quotations? (ANA, etc)

[brownbook]

Quoting patients is good charting practice. But I still think your problems, situations, are not really related to quoting patients. You can write a book quoting what the patient said. It doesn't matter. What you do next matters.

You can't just chart, patient removed fetal monitor, patient states, "I don't need this ****ing thing." You need to chart, doctor notified of patients refusal, doctor said. "I will come in to to talk to the patient." Or write a telephone order, "Do not place patient on fetal monitor." Be sure to quote back to the doctor, before he hangs up, "so I will write as an order in the chart, ""do not place patient on fetal monitor.""

And even if you get the doctor order you should notify your charge nurse. You and the doctor would be sued if there was a bad outcome, any lawyer would argue the patient is not responsible to make medical decisions. If your gut told you this was a bad situation, even with the doctor and charge nurse being aware, you can and should go up the chain of command if you felt this was bad medical/nursing care.

All the quoting in the world does not relieve a nurse of her responsibility to care for a patient no matter how much the patient is swearing.

[GHGoonette, BSN, RN]

When I was taught the Nursing Process, back in the days when dinosaurs roamed the earth , I was told that I had to record the patient's exact words and responses to my questions. In the case of family members, they do not fall under the care plan, so your course of action should be to record that you were hindered in your duty by the aggressive husband and prevented from communicating with the patient.

Management's task should have been to have him removed from the premises, unless the patient insisted he be allowed to remain. I'd have called in her doctor to reason with him-after all, what is the point of even keeping her in hospital if staff are being prevented from carrying out essential care?

[nurse2033, MSN, RN]

I don't think you can be sued for writing the truth. If you are documenting that the husband was giving you a hard time I would save the ink. But, let's say you were unable to provide fundal massage because of him, his statement would be justification for why you did not. Although you would then have to document what you did and said to try and convince him it was OK, and his wife. I save that kind of documentation usually as explanation of why something that might normally have been done, was not. (Obviously essential taks must be done anyway).