Thursday, March 17, 2011

Too Much Charting?

A couple of weeks ago the department was absolutely swamped and really short staffed due to a particularly heinous strain of cold and gastro making its rounds with the staff. The staffing situation was dire enough that the manager changed her shirt into a scrub top and started helping out. It was quite a funny sight to see a woman in a pencil skirt, flats and a scrub top walking around the department carrying urinals full of hematuria. But I digress – that’s not the point. She eventually triaged a patient to fast track for back pain. Long story short, the woman was a drug seeker who’s very familiar to most of the staff. She didn’t let me examine her nor did she let the doctor do the same. Eventually, the doc told her to eff off (not quite like that, but her intention could not be mistaken) and that she could either get toradol or nothing before leaving. She then pretended to have a syncopal episode (seriously, how many times does a syncopal episode result in someone falling neatly onto the egg-crated mattress?). When she realized that the nurse was clearly ignoring her, she sat up and started to threaten her and swear at her using profanities that would offend a seasoned sailor’s sensibilities. Rightly so, my colleague didn’t put up with it for too long before she called security and had her ass dumped back out into the cold. Like any good nurse, she then documented. Then documented some more. She also included some direct quotes from her in her documentation because the patient was just that vile.

Lo and behold, this issue was brought up during our education day by the nurse clinician and our manager. Their position was that including some of her direct quotes was unprofessional and that now this charting would follow the patient around in her future encounters with the healthcare system.

I do see my manager’s point of view. Once something is written, there’s no taking it back. If she ever cleans up and has to access an ER again, this documentation is going to unfavourably affect how another nurse treats her. I can also see how in the midst of illness, one says things that they later regret and a person’s actions in one moment of time are not necessarily reflective of who they are. However, had I been in my colleague’s place, I probably would have documented in a similar style. Why? I’ve also dealt with this patient many times before and each encounter ends in almost the exact same way. A friend of mine who works in an ER across town also gets sworn at by her every time he invokes the fury of the triage gods. And yet, the only thing I’ve seen documented is that “patient is verbally abusive to staff”. I don’t think that this statement covers exactly how vile she is towards the staff. We regularly use quotes to capture what patients tell us so I don’t see why we can’t use direct quotes to document verbal abuse thrown our way. Moreover, in the unlikely scenario if she ever decided to sue my colleague, she would have documentation about the patient’s thoroughly reprehensible behaviour to back up her actions.

Obviously, I’m still not decided on where exactly I stand on the issue but I feel that I better pick a position soon because she’s not going to the only aggressive and abusive patient I’ll deal with.

27 comments:

NP Odyssey said...

If she ever cleans up? Or what if she never does, either way that is not your problem. I document on these patients, where do you draw the line?
But, I also have no problem documenting on doctors if they are out of line. Being a travel nurse for so many years you learn to cover your a**. You don't want to run into a he said, she said situation especially with patients.

Heidi said...

If it's seriously abusive, or at all threatening, I direct quote the shit out of it. And I would think that if she ever did truly change her ways, her (hopefully improved) behavior would override the effects of any old charting.

Andi, On Call RN said...

seriously covering your behind is never a bad idea and how is it unprofessional when its a standard of practice to use quotes of our patients to describe how they are feeling or reacting. You have to document properly how they are refusing care. Working in an ICU at a verteran's hospital I get a lot of these situations and I think its always better to air on the side of writing too much when it comes to charting. It's our license on the line at the end of the day, right?

Anonymous said...

complete charting now may help a future practitioner make a quicker safer correct decision, understanding that there are traps. she might clean up. she might really be ill.

Old MD Girl said...

I see your point both ways, Maha. I can say I've seen myself personally become erroneously biased by things I read in the chart about a patient's past behavior. On the other hand, it's important to CYA as well, and to protect yourself, the hospital, and future staff who see her. I will say though, the charts with the direct quotes can be a pretty entertaining read.

Honey said...

I understand why direct quotes were charted, but I think I would have put that pt. was verbally abusive and maybe included use of obscene language and threatening behaviour to justify the security being called. By the way, that was my favorite part of the story- the pt. being kicked out. No nurse should ever be threatened or abused by any pt. ever.

Nurse-to-be said...

As long as the documentation is objective and factual, there shouldn't be a problem. It may follow her, but she said it!

Anonymous said...

I also think documenting it is the correct choice. If she said it, and you're quoting it directly, then you're not doing anything wrong.

Word verification: gated, entitled abusers should be gated away from the rest of us.

RehabRN said...

Anyone can have a bad day. That's why I'm as objective as possible.

I figure if I ever end up in court, I'll just say, "This is what he/she said this day, that day, whatever day. Could there be a pattern?"

If they fly frequently enough, there's always a pattern, and it ain't just over the airport!

gabbiana said...

ER resident... I quote. But I kind of get a kick out of writing four-letter words in my professional documents.

ZoeRN said...

As someone already posted, as long as the charting is factual and objective, what's the problem? Yeah, sure it will follow her to subsequent visits, but it probably should.

Think of it this way: what if the abuse wasn't just verbal, but physical? Say, for example, she punched your colleague in the face. This would be something you would want to follow her on subsequent visits, because you would be protecting your colleagues from violence. Why should verbal abuse be any different?

shrtstormtrooper said...

I'm of the opinion that if they said it, it's fair game. And if for some reason the case ever did go to court, "pt verbally abusive to staff" doesn't really cover what happened. A few quoted f-bombs though...that gets the point across nicely.

Regardless, do what you feel is right. I'm pretty sure I picked up that quote from a Star Wars movie or something, but it seems appropriate.

Kim said...

Chart exactly what was said as it was said, in quotes. That is as objective as it gets.

Should said patient ever decide to sue, you had better believe that will weaken her/his case faster than anything.

The nurse clinician and your manager are totally wrong. You have the right to document any threatening or abusive behavior exactly as it happens. No more, no less.

clairesmum said...

I agree, documenting a direct quote is fine. The purpose of charting is to document what did occur - not to make anyone else look 'good' or 'bad.' The verbally abusive behavior and the presentation of inconsistent physical sx is a flag for drug seeking behavior. You need to SHOW why the decision was made to deny opiates, etc. This is the way you show that the medical care WAS appropriate to her needs, as assessed by RNs and MDs.

kate said...

I used direct quotations ALL THE TIME when dealing with irate patients. I've always been of the mindset that in order to best cover my ass, I need to document, document, DOCUMENT!! As far as I see it, if you feel that it's appropriate to cuss me out, call me names and threaten me, then I find it more than appropriate to include that information in your medical record so that those that have to encounter you later have some idea of what they're dealing with.

I understand what the manager is trying to say, but I have no problem with that record following the patient around if that's what they did. We're all grown ups. Time to live with the consequences of our actions.

StorytellERdoc said...

This was a thought-provoking post! I tend to think that as long as you quotation the near-exact patient words, it's all okay. If we have to own our words, why shouldn't they?

Regardless, it sucks to be on the receiving end of a vicious tirade, something occurring more commonly in medicine (especially the ER) these days. Sad...I hope your friend boxed this experience in the right place.

Anonymous said...

I was deposed on a pressure ulcer than turned into septic shock...of course, per the patient, no one EVER changed his drsg, told him to stay off that side, etc, etc. Lots of charting of "pt. refuses care." Not from me. I ALWAYS quote, and as Kate said, if they say it I will write. So, this poor ignored pt. had my notes, along the lines of "Entered room to provide wound care. Pt throws his TV remote and states in a lound voice, "Get the fuck out of my room, bitch. I ain't letting no one touch me."

Guess whose lawsuit went "bye-bye"

Pattie, RN

Bats, RN said...

Why is it unprofessional to use quotes? Do we really need to protect patients from the potentially embarrassing things they have said or done?

Scrub Ninja said...

I'm beginning to hate that word "unprofessional." It has become a meaningless catchall for every possible thing a patient or supervisor doesn't like at that moment. (I suppose the professional nurse makes everyone happy all the time.)

IMO it is completely appropriate to document exact words. My professors keep saying we are supposed to chart observed facts, rather than judgements, whenever possible. "Abusive" is a judgement call and therefore open to interpretation, but an exact quotation is an observed fact.

Persephone's Maiden said...

I completely agree with scrub ninja's post. I used to work patient care on the substance abuse ward and you can bet every time I got a harmful threat or sexually harassing comment, it got charted.

donshanrandall said...

Hi Maha (and everyone else). I am a nursing student searching for an informative and entertaining blog to follow (looks like I found it !!) As far as documentation goes, I believe in being as thorough as is necessary to describe the situation. Quotes are a great tool, but if policy requires some restraint perhaps it would be wise to develop an acronym for habitually abusive pts.

Lois said...

As I see it, the documentation should be accurate, as it is a legal document. If it follows the patient around, well, there you go: we have to take responsibility for our words and our actions. If she ever cleans up her act, she can explain and apologise and prove herself to be a better person, and then that will be documented.

Laney said...

Direct quote all day. She can document rehab if she ever cleans up.

Adrian said...

Maha,

I think this was an attempt by the Clinical Nurse and Manager to make you look bad.

It happens more often than one wishes to believe.

Abuse of power/authority fed by jealousy and fragile Egos.

Is it not ironic that you get a report or citation in your file now as a result of this, yet they decry a perceived 'negative' entry in to the patient's chart?

Et tu, Brute?

Food for thought.....watch your back from patients and colleagues!

Not in a paranoid schizophrenic way ....but....just keep an open mind.

40-ish said...

It is a shame that your manager put that on your plate-I feel you did the absolute right thing not only to CYA, but to show exactly what went on. In 10 years if that case went to court, saying "she was verbally abusive to the staff" does NOT CUT IT. If it's not charted it didn't happen. I am NOT PC in my charting. I freakin' tell it like it is. Period.

Jaedpact said...

over 25 comments. I encourage you to forward a link to your managers email address. You aren't alone, indeed it seems your point of view is the majority among nurses. Be vocal!!!

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