Record your client's response to what you do and say. Perhaps their health care professional simply explained the importance of good hygiene, but for some patients it may be a huge effort to figure out what exactly ‘good hygiene’ means. Use of patient-centered, nonjudgmental language will better preserve the physician/patient alliance. Document what is spoken or avoided, tone of voice, and any changes to the initial mood, attitude, actions, gestures and body language. Terms to describe pleasant behavior include affable, friendly, outgoing and amiable. Other positive-behavior terms include tactful, candid and courteous. Here, you should document objective, repeatable and measurable facts about the patient’s status. should do or “how” to do it because they lack the resources to do the necessary research. Findings from a physical examination. For example, you might document that a patient is continually repeating the same words or ideas (perseveration) or is stringing words together that do not make any sense (word salad). Document the reason for restraint and that you explained the reason to the patient and family. If the patient receives a hard copy of material that was printed from the EHR and this copy is annotated to add additional clarification, emphasize a section or delete a section, scan a copy of this changed form into the EHR in order to document the true copy the patient received. Document what you did or observed, not your opinion. Cooperative behaviors include helpful and responsive. The flowsheet should include the following: patient behavior that indicates the continued need for restraints; patient… Behaviour is put together of many different “blocks” As opposed to medical assessments, the patients’ full cooperation is not required to assess their mental status. For example, “Patient appears pale and in discomfort.” In this section, also include observations and vital signs. Ł “Do you think someone or some group intend to harm you in some way?” Ł [In response to something the patient says] “What do you think they meant by that?” Ł “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into your head? To avoid bias when documenting a patient's statements, document the patient's exact words using quotation marks. Document any recommendations that you make that the patient outright rejects, and document the patient's words. Never use labels to describe a patient or a patient's behavior. You can use a flowsheet to document assessments. An individual who exhibits dependent behaviors could be described as docile, eager to please or accommodating. Consider the type of language you would find acceptable in documents describing the care provided to you or a loved one. Whenever possible, describe behavior by … Cooperation not Required. • If a nurse trials a patient off of restraints and must place the patient back into restraints, a new order is required • Restraint type used must match the patient behavior being exhibited and the MD order • Chemical Restraint: o Medication(s) are used in doses and/or combinations intended to incapacitate the patient to restrict their Instead, write something like, “patient ate approximately 50% of food on lunch tray.” If you’re unclear, others either won’t understand what you meant, or worse, may assume that for some reason you’ve deliberately omitted clinical information. 4. You may include objective observations about how the patient appears from the end of the bed. This will be valuable evidence if/when needed for CDPH, law enforcement, discharge of patient, etc. Thoroughly document patient’s behavior (specifically and objectively), behavioral interventions, and patient’s response to interventions in the patient’s medical record.