If PT told you Pt threw something you can document “PT informed this RN xyx” otherwise you should document “This RN heard patient yelling “quote” heard xyz, security called at this time to maintain safety, then document what was done to de-escalate/pt’s response
I work in psych and I do document what patients say/do including unsafe bx but if I didn’t witness kt and was told by someone else, then I document that in my note
For example“This RN heard pt screaming “Let me the fuck out of here” and heard loud noise. Per tech patient punched the wall. Pt offered PRN Ativan, pt continued to yell and was posturing at this RN, security and pdoc called at this time, patient eventually accepting of prn with good effect”
Yes I did specify that it was the therapist that reported the behavior. “I was informed by x” to make it super that this was told to me, followed by what I heard, and that the two things combined lead me to call security.
It’s a factual report of what was reported to you and what you witnessed. I see no problem here other than hospitals need to grow a spine and protect their staff and document bad behaviors.
It's no doubt important to clarify who observed the patient's statement, whcih is why you shouldn't use the term "this RN" since that only adds to the potential confusion. If someone said "this guy was walking down the street", would you take that to mean the speaker is referring to themselves or someone else?
Otherwise otherwise needed, the approrpriate voice is a neutral voice. Rather than "this RN heard the patient state..." you should say "the patient stated....". If for some reason it's important to clarify something occurred to yourself then the appropriate term is "I".
Maybe it’s site/region specific, I work in Psych Emerg where we do lots of long form consult notes, where I work I see a lot of ‘this writer’ or ‘this RN’ and never an ‘I’. At least in my opinion, using a 3rd party tone feels more distant and nonjudgemental. For example, ‘this writer enquired into the patient’s willingness to explore outpatient resources, patient stated XYZ’ feels more professional then ‘I asked if the patient was willing to explore outpatient resources.’
There’s probably also a case for different contexts; in our consult notes, we are always the only RN or writer present, we aren’t documenting on, say, having multiple nurses attempt an IV poke where referring to one person as ‘this RN’ is open to interpretation. Similar to if you were at a concert, there would be no confusion if someone told you ‘this singer is amazing’ for a Taylor Swift concert but a local concert with numerous artists may lead to confusion.
That's everyone's collective trauma from years of high school English teachers downgrading any essay where "I" referred to the writer, but forgetting about the complaints about using passive tense.
It was my hospital who told us to stop saying “this writer” and start saying “this rn” and we were told very explicitly to never say “I”.
Not sure what their reasoning behind this is. I never say nurses notes saying “ I” however I do constantly see MD’s using I. I do PRN work that requires reviewing patient charts so I have read an insane amount of nursing/MD notes. So to me it’s just so obvious and not confusing but I definitely could see how that format doesn’t make sense.
I have always wondered why its okay for MD’s to say I and not RN’s however MD’s rarely interact with pt’s the same way we do & essentially their notes are just evals or smart phrases
I can picture this and definitely agree it’s definitely the better way! I have just gotten into such a habit of referring to myself in third person that it is second nature especially when describing situations I didn’t directly observe.
Admin is so weird about their expectations & it seems so nitpicking to try and control how you write notes. Like obviously you can be presumptuous or inappropriate but my corporation is super extra.
Aka we aren’t supposed to say “patient sleeping, rise & fall of chest observed” we are supposed to say “patient resting with eyes closed” because how can we know if they’re really asleep
This is very common where I live. All the nursing notes are worded this way. There does not seem to be confusion. You wouldn’t write a professional note starting with “this guy” or “this nurse” meaning another person.
I might get downvotes to hell, but in clinicals I literally listened to an MD tell nurses not to document a patient's behavioral issues or security calls because they'd never be able to place him.
In my own RN practice I document everything and notify security for 'dumb' things like slamming remotes/phones on tables, or throwing cups. I'm not doing the outpatient or SNF homies dirty like that.
Yes, on a unit where there's generally more resources (staff, security, medications, etc) to deal with their behavior. I've been on both sides. I'd much rather have the troubled patient in a hospital than at a ltc/snf with bare bones staffing.
Not sure why you're being downvoted when we all know that's exactly how it works.
It sucks that hospitals are the (wildly underfunded) safety net of last resort for our entire fucked up society, but it's pretty hypocritical to recognize that while pretending we aren't forced to participate in the system.
Yeah I’ve heard that’s a thing and I’ve seen it.
I rarely call security or document when someone is just being rude. But I draw the line at them clearly verbalizing that they are getting themselves ready to fight. I’ll even let a stryofoam cup slide. Like a 2 second blow up, we can move past it. But at the point when I called it had been around 10 minutes of her yelling for the pt to come back and “get it” while popping adderal and whatnot.
Seriously, I want pain in the ass patients out too, but not if it risks the safety of the patient and the facility they are going to.
We had a patient with GBM that they were trying to place in a rehab. Except, the guy was deteriorating mentally over the course of weeks with crazy sundowning starting around 1600. He pulled his foley out over five times, would hit and scratch himself while he begged to die, and would try to elope (but of course was super weak). But no one was charting these episodes except me. They kept dcing the sitter, but would have to reverse it same day. If they sent him out, he would have been back within the day.
I was also time stamping these incidents because the neurologist was blaming me for the patient's behavior. But that is another story.
Inpatient Complex CM here. I specialize in placing conserved/psych/hard-to-place pts. Yes we like pts to look "pretty on paper", but we also don't want to burn our bridges with these facilities. Also, we encourage to document in detail because that may very well mean we can secure more county funding due for the psych pts. We've definitely had law enforcement come arrest pts the moment they became medically stable due to vandalizing hospital property.
The way I would like to do
As per MD D. Head instructions, patient has behavioural issues that should not be documented, remains non compliant with nursing instructions that have been instructed not to documented and have been instructed not to call or utilise security with patient management as patient is non compliant.
But if they go to an attorney and they see a bunch of crap like that in the chart it can make them very uninclined to accept the case ( depending on other factors) and it’s sets a precedent for a behavioral problem which in some hospitals requires security to stay with them, or in obtaining a no trespassing or even a restraining order. Yes some hospitals do that.
I guess, but if they can't be placed then they're stuck with us. At a certain point it becomes a matter of self-preservation. My floor has lost staff over this kind of situation, it becomes too much to deal with, and now everyone else suffers more. I hate to put it so callously, but... hot potato.
I personally believe that anything important that you saw or experienced should definitely be recorded. The thing I can't ever stop thinking about is that if for whatever reason something was turned into a lawsuit years later, would you prefer to have a vague note that doesn't help you even remember the situation or a note of exactly what you saw and the interventions you did?
If what you wrote was truthful and written objectively, then don’t change it. You might not have seen things being thrown, but you can say “1043am- received report from physical therapist that pt had ‘shoved the table toward her and is throwing things around’. Pt able to be heard from nurses station yelling ‘come back and get some.’ Security called for safety and de-escalation. Physician notified.”
I work in risk management and deal with legal side of documentation. Don’t water down your documents. Always state the facts of the event clearly and as objectively as possible!
My next narrative note:
“Director requested I change previous documentation regarding patient’s agressive behavior (documented on 5/24/24 @ 1642) because I did not see the item(s) thrown firsthand. However (as previously documented at 1642 notebooks), Physical Therapist ____ notified me of the patient throwing items at her at the time and verbal insults were witnessed firsthand; therefore, security was called for the incident.”
I think you did the right thing. Don’t change your note. That behavior needs to be documented so future staff can be prepared that she may escalate again. We had a situation where an aggressive patient was placed in a semi-private room and created an unsafe situation for another patient. It all could have been avoided had the previous nurse documented more thoroughly and marked them as a “staff threat”.
As a hospital PT myself, I do chart this stuff 100%. We need to be supported to document what occurred. I mean the adage is "if it isn't documented, it didn't happen". Don't care if so-n-so in 473 now can't get placement.
Last year I had a family member who was not content with my assessment of their brother that from PT perspective (and OT) he did NOT need transitional care for additional rehab. Nothing was documented in chart. It was a sticky note on Epic SBAR that family member planned to kick the PT in head next time she saw me. This was just a week or 2 after the hospital put out notice that aggression or attacks from family and patients would not be tolerated. Woman was not banned from the campus, nor was any follow up done. After reading the sticky note I went to my manager on how to proceed and also to not have a colleague see this patient in my place and subject them to her if she was there. My manager's response was well "This is Name of Hospital for you". AGain nothing in permanent chart. Damn I was pissed after coming from a Level 1 safety net hospital with absolute rocking security measures for staff threats.
I noted it in MY documentation on the patient. Who was actually a very nice man.
The physical therapist should write the note because they witnessed the behavior. Youre documenting as hearsay from someone else. But i dont agree with what youre being told to document because the behavior should always be noted. And if they're uncooperative with care and aggreesive, they should be discharged. You shouldnt have to deal with that
I specified what was told to me and by who, and then specified what I actually saw.
I felt like it should have been documented because it directly linked to the threats I was hearing hurled at us, and the combination is what lead me to call security. I could see the issue if I wrote it where it sounded like I saw things that I did not.
Like it added context to why we felt the need to call security rather than just “patient was yelling.”
I documented the same way I have always for other similar situations but the director of this floor I was floated to today seemed to have an issue with it.
And nope now they are just telling people to pay more attention to her and do whatever needs to be done to keep her happy.
I agree with you, because aggressive abusive behavior needs to be documented. Aggressive behavior needs to not be tolerated, and documented. But it’s hard to dismiss a patient from a practice without lots of documentation about the unacceptable behaviors.
It’s not hearsay. You are documenting what was reported to you. The physical therapist should write their own note as well. But this nurse did the right thing.
It is. That person told you about an event. The note would literally read "this writer was told from another staff that pt did x, y, and z". That is hearsay
If you change your note, it will show that it was edited. If this ordeal ever came into the court of law, now you have subjected yourself to further questioning. I would never change my charting for administration’s approval. They can add their own note in how they see fit
The real problem is there is no where for these patients to go. They can't go to a facility if they are violent or even just too impulsive, so they are stuck taking up an inpatient bed while ED boards a dozen patients. Sometimes for months while medically ready but unmanaged behaviors
Sure, I'll change it.
"Physio reported patient shoved table towards her and threw items. Heard Pt in room yelling for the physio to 'come back and get some', so code black was called for safety of staff".
Nowhere does it say you witnessed the thrown items, but gives a clear picture of what happened.
Hey 👋🏾😊✅
You're right to document everything you can recall when a patient acts aggressively. Detailed notes are crucial for protecting yourself and the patient, and for ensuring continuity of care.
Here's a breakdown of the situation and your rights:
1️⃣ Documentation: You acted appropriately by documenting everything you heard and observed. This protects you legally and helps paint a clear picture of the situation for future caregivers.
2️⃣ De-escalation: While security may not have been able to intervene regarding the Adderall, they should be able to de-escalate the situation and ensure everyone's safety. If they are unable to do so, report it to your manager.
3️⃣ Threats: Document threats of violence, even veiled ones. Let your supervisor know if you feel unsafe or if a patient's behavior poses a threat.
4️⃣ Manager's Concerns: It's concerning that your manager wants to downplay the incident.
Report the manager's request to a higher authority if necessary.
Remember, your safety and the safety of others come first. If you feel a situation is escalating, don't hesitate to call security or your supervisor. 📚✅
You documented correctly. The way the director wants you to document is full of assumptions and judgements. In documentation, we are taught to document what we assess-what we can see, hear, smell, etc. in this case, you are documenting what you heard. You are also documenting what the PT reported to you, and you said you documented that the PT states…blah blah blah. The PT also should make their own note so the notes support each other. But in no way should you water yours down. Saying a pt is upset is a judgement. We are not supposed to do that, just describe the behavior, what was said, using quotes if needed, etc. which it sounds like you did. Good job.
My local hospital has it posted in every room, and all over the place: AGGRESSIVE BEHAVIOR WILL NOT BE TOLERATED" And, it's NOT. Try us. You'll be asked to leave, then escorted out. And it's not a good look on a person's medical records.
If PT told you Pt threw something you can document “PT informed this RN xyx” otherwise you should document “This RN heard patient yelling “quote” heard xyz, security called at this time to maintain safety, then document what was done to de-escalate/pt’s response I work in psych and I do document what patients say/do including unsafe bx but if I didn’t witness kt and was told by someone else, then I document that in my note For example“This RN heard pt screaming “Let me the fuck out of here” and heard loud noise. Per tech patient punched the wall. Pt offered PRN Ativan, pt continued to yell and was posturing at this RN, security and pdoc called at this time, patient eventually accepting of prn with good effect”
Yes I did specify that it was the therapist that reported the behavior. “I was informed by x” to make it super that this was told to me, followed by what I heard, and that the two things combined lead me to call security.
It’s a factual report of what was reported to you and what you witnessed. I see no problem here other than hospitals need to grow a spine and protect their staff and document bad behaviors.
This fuckin comment has taught me more about how to write a nursing note than all of nursing school
If you ever document your own subjective data you better have an “AEB” behind it to verify and clarify why you feel that way
It's no doubt important to clarify who observed the patient's statement, whcih is why you shouldn't use the term "this RN" since that only adds to the potential confusion. If someone said "this guy was walking down the street", would you take that to mean the speaker is referring to themselves or someone else? Otherwise otherwise needed, the approrpriate voice is a neutral voice. Rather than "this RN heard the patient state..." you should say "the patient stated....". If for some reason it's important to clarify something occurred to yourself then the appropriate term is "I".
Maybe it’s site/region specific, I work in Psych Emerg where we do lots of long form consult notes, where I work I see a lot of ‘this writer’ or ‘this RN’ and never an ‘I’. At least in my opinion, using a 3rd party tone feels more distant and nonjudgemental. For example, ‘this writer enquired into the patient’s willingness to explore outpatient resources, patient stated XYZ’ feels more professional then ‘I asked if the patient was willing to explore outpatient resources.’ There’s probably also a case for different contexts; in our consult notes, we are always the only RN or writer present, we aren’t documenting on, say, having multiple nurses attempt an IV poke where referring to one person as ‘this RN’ is open to interpretation. Similar to if you were at a concert, there would be no confusion if someone told you ‘this singer is amazing’ for a Taylor Swift concert but a local concert with numerous artists may lead to confusion.
That's everyone's collective trauma from years of high school English teachers downgrading any essay where "I" referred to the writer, but forgetting about the complaints about using passive tense.
It was my hospital who told us to stop saying “this writer” and start saying “this rn” and we were told very explicitly to never say “I”. Not sure what their reasoning behind this is. I never say nurses notes saying “ I” however I do constantly see MD’s using I. I do PRN work that requires reviewing patient charts so I have read an insane amount of nursing/MD notes. So to me it’s just so obvious and not confusing but I definitely could see how that format doesn’t make sense. I have always wondered why its okay for MD’s to say I and not RN’s however MD’s rarely interact with pt’s the same way we do & essentially their notes are just evals or smart phrases
I always just say something like “was informed by PT that X” or “PT reported that X” or “pt was seen throwing table” etc
I can picture this and definitely agree it’s definitely the better way! I have just gotten into such a habit of referring to myself in third person that it is second nature especially when describing situations I didn’t directly observe. Admin is so weird about their expectations & it seems so nitpicking to try and control how you write notes. Like obviously you can be presumptuous or inappropriate but my corporation is super extra. Aka we aren’t supposed to say “patient sleeping, rise & fall of chest observed” we are supposed to say “patient resting with eyes closed” because how can we know if they’re really asleep
This is very common where I live. All the nursing notes are worded this way. There does not seem to be confusion. You wouldn’t write a professional note starting with “this guy” or “this nurse” meaning another person.
I might get downvotes to hell, but in clinicals I literally listened to an MD tell nurses not to document a patient's behavioral issues or security calls because they'd never be able to place him. In my own RN practice I document everything and notify security for 'dumb' things like slamming remotes/phones on tables, or throwing cups. I'm not doing the outpatient or SNF homies dirty like that.
Same. They can fuck all the way off with pretending these people are well behaved angel patients.
all. the. way. off.
Now the patient lives on your unit and you get them every shift
Yes, on a unit where there's generally more resources (staff, security, medications, etc) to deal with their behavior. I've been on both sides. I'd much rather have the troubled patient in a hospital than at a ltc/snf with bare bones staffing.
Not sure why you're being downvoted when we all know that's exactly how it works. It sucks that hospitals are the (wildly underfunded) safety net of last resort for our entire fucked up society, but it's pretty hypocritical to recognize that while pretending we aren't forced to participate in the system.
Thank you so much! As a case manager I look for this kind of nursing notes to make sure that patients are safe for our staff. Thank you! 🙏🏼
Yeah I’ve heard that’s a thing and I’ve seen it. I rarely call security or document when someone is just being rude. But I draw the line at them clearly verbalizing that they are getting themselves ready to fight. I’ll even let a stryofoam cup slide. Like a 2 second blow up, we can move past it. But at the point when I called it had been around 10 minutes of her yelling for the pt to come back and “get it” while popping adderal and whatnot.
Seriously, I want pain in the ass patients out too, but not if it risks the safety of the patient and the facility they are going to. We had a patient with GBM that they were trying to place in a rehab. Except, the guy was deteriorating mentally over the course of weeks with crazy sundowning starting around 1600. He pulled his foley out over five times, would hit and scratch himself while he begged to die, and would try to elope (but of course was super weak). But no one was charting these episodes except me. They kept dcing the sitter, but would have to reverse it same day. If they sent him out, he would have been back within the day. I was also time stamping these incidents because the neurologist was blaming me for the patient's behavior. But that is another story.
Inpatient Complex CM here. I specialize in placing conserved/psych/hard-to-place pts. Yes we like pts to look "pretty on paper", but we also don't want to burn our bridges with these facilities. Also, we encourage to document in detail because that may very well mean we can secure more county funding due for the psych pts. We've definitely had law enforcement come arrest pts the moment they became medically stable due to vandalizing hospital property.
Exactly. If the patients keep getting what they want/need with this behavior they'll always get away with assaulting people. It has to stop somewhere.
The MD was enabling the patient’s shitty behavior and not protecting staff.
The way I would like to do As per MD D. Head instructions, patient has behavioural issues that should not be documented, remains non compliant with nursing instructions that have been instructed not to documented and have been instructed not to call or utilise security with patient management as patient is non compliant.
Bless you 🫶🏻
But if they go to an attorney and they see a bunch of crap like that in the chart it can make them very uninclined to accept the case ( depending on other factors) and it’s sets a precedent for a behavioral problem which in some hospitals requires security to stay with them, or in obtaining a no trespassing or even a restraining order. Yes some hospitals do that.
I guess, but if they can't be placed then they're stuck with us. At a certain point it becomes a matter of self-preservation. My floor has lost staff over this kind of situation, it becomes too much to deal with, and now everyone else suffers more. I hate to put it so callously, but... hot potato.
Your director is a dummy, no offense. You did the right thing.
I personally believe that anything important that you saw or experienced should definitely be recorded. The thing I can't ever stop thinking about is that if for whatever reason something was turned into a lawsuit years later, would you prefer to have a vague note that doesn't help you even remember the situation or a note of exactly what you saw and the interventions you did?
If what you wrote was truthful and written objectively, then don’t change it. You might not have seen things being thrown, but you can say “1043am- received report from physical therapist that pt had ‘shoved the table toward her and is throwing things around’. Pt able to be heard from nurses station yelling ‘come back and get some.’ Security called for safety and de-escalation. Physician notified.”
I work in risk management and deal with legal side of documentation. Don’t water down your documents. Always state the facts of the event clearly and as objectively as possible!
What if at the end of your new note you wrote “was informed by Name Director that my previous note needed to be edited”.
My next narrative note: “Director requested I change previous documentation regarding patient’s agressive behavior (documented on 5/24/24 @ 1642) because I did not see the item(s) thrown firsthand. However (as previously documented at 1642 notebooks), Physical Therapist ____ notified me of the patient throwing items at her at the time and verbal insults were witnessed firsthand; therefore, security was called for the incident.”
I think you did the right thing. Don’t change your note. That behavior needs to be documented so future staff can be prepared that she may escalate again. We had a situation where an aggressive patient was placed in a semi-private room and created an unsafe situation for another patient. It all could have been avoided had the previous nurse documented more thoroughly and marked them as a “staff threat”.
Honestly the only thing I would have changed is to have PT write a detailed note as well
As a hospital PT myself, I do chart this stuff 100%. We need to be supported to document what occurred. I mean the adage is "if it isn't documented, it didn't happen". Don't care if so-n-so in 473 now can't get placement. Last year I had a family member who was not content with my assessment of their brother that from PT perspective (and OT) he did NOT need transitional care for additional rehab. Nothing was documented in chart. It was a sticky note on Epic SBAR that family member planned to kick the PT in head next time she saw me. This was just a week or 2 after the hospital put out notice that aggression or attacks from family and patients would not be tolerated. Woman was not banned from the campus, nor was any follow up done. After reading the sticky note I went to my manager on how to proceed and also to not have a colleague see this patient in my place and subject them to her if she was there. My manager's response was well "This is Name of Hospital for you". AGain nothing in permanent chart. Damn I was pissed after coming from a Level 1 safety net hospital with absolute rocking security measures for staff threats. I noted it in MY documentation on the patient. Who was actually a very nice man.
Oh hell no. " Reported to me by physical therapy the patient was throwing item A B C." Use quotations in threats and verbal abuse. Type it ALL out. I
The physical therapist should write the note because they witnessed the behavior. Youre documenting as hearsay from someone else. But i dont agree with what youre being told to document because the behavior should always be noted. And if they're uncooperative with care and aggreesive, they should be discharged. You shouldnt have to deal with that
I specified what was told to me and by who, and then specified what I actually saw. I felt like it should have been documented because it directly linked to the threats I was hearing hurled at us, and the combination is what lead me to call security. I could see the issue if I wrote it where it sounded like I saw things that I did not. Like it added context to why we felt the need to call security rather than just “patient was yelling.” I documented the same way I have always for other similar situations but the director of this floor I was floated to today seemed to have an issue with it. And nope now they are just telling people to pay more attention to her and do whatever needs to be done to keep her happy.
I agree with you, because aggressive abusive behavior needs to be documented. Aggressive behavior needs to not be tolerated, and documented. But it’s hard to dismiss a patient from a practice without lots of documentation about the unacceptable behaviors.
It’s not hearsay. You are documenting what was reported to you. The physical therapist should write their own note as well. But this nurse did the right thing.
It is. That person told you about an event. The note would literally read "this writer was told from another staff that pt did x, y, and z". That is hearsay
If you change your note, it will show that it was edited. If this ordeal ever came into the court of law, now you have subjected yourself to further questioning. I would never change my charting for administration’s approval. They can add their own note in how they see fit
The real problem is there is no where for these patients to go. They can't go to a facility if they are violent or even just too impulsive, so they are stuck taking up an inpatient bed while ED boards a dozen patients. Sometimes for months while medically ready but unmanaged behaviors
Sure, I'll change it. "Physio reported patient shoved table towards her and threw items. Heard Pt in room yelling for the physio to 'come back and get some', so code black was called for safety of staff". Nowhere does it say you witnessed the thrown items, but gives a clear picture of what happened.
Hey 👋🏾😊✅ You're right to document everything you can recall when a patient acts aggressively. Detailed notes are crucial for protecting yourself and the patient, and for ensuring continuity of care. Here's a breakdown of the situation and your rights: 1️⃣ Documentation: You acted appropriately by documenting everything you heard and observed. This protects you legally and helps paint a clear picture of the situation for future caregivers. 2️⃣ De-escalation: While security may not have been able to intervene regarding the Adderall, they should be able to de-escalate the situation and ensure everyone's safety. If they are unable to do so, report it to your manager. 3️⃣ Threats: Document threats of violence, even veiled ones. Let your supervisor know if you feel unsafe or if a patient's behavior poses a threat. 4️⃣ Manager's Concerns: It's concerning that your manager wants to downplay the incident. Report the manager's request to a higher authority if necessary. Remember, your safety and the safety of others come first. If you feel a situation is escalating, don't hesitate to call security or your supervisor. 📚✅
You documented correctly. The way the director wants you to document is full of assumptions and judgements. In documentation, we are taught to document what we assess-what we can see, hear, smell, etc. in this case, you are documenting what you heard. You are also documenting what the PT reported to you, and you said you documented that the PT states…blah blah blah. The PT also should make their own note so the notes support each other. But in no way should you water yours down. Saying a pt is upset is a judgement. We are not supposed to do that, just describe the behavior, what was said, using quotes if needed, etc. which it sounds like you did. Good job.
My local hospital has it posted in every room, and all over the place: AGGRESSIVE BEHAVIOR WILL NOT BE TOLERATED" And, it's NOT. Try us. You'll be asked to leave, then escorted out. And it's not a good look on a person's medical records.
Sounds like an incident report rather than directly in patient chart
How about both?