In a previous post, I shared an example of real charting in a health record that clearly included language that could be considered stigmatizing and biased.  In the next post, we discussed which words and phrases implied bias and stigmatization, and so today I want to share one possible way (and there are many) the progress note could be written so as to be unbiased and pertinent to the complaint.  I also included what the nurse should have done in an examination of Mr. Jones.  

To refresh your memory, here is the original health record documentation:

 “Patient is a 38-year-old black male who came to the medical unit via wheelchair after he allegedly had a seizure and fell off the top bunk. He is an opiate and benzodiazepine addict, long term, with at least four failed rehab attempts in the last two years. He supposedly had a seizure and rolled off the top bunk and is now demanding pain medication. He admits to trying to get “anything” (drug) from his cellmates to help with the detox, but “no one had anything” that could help. Right now, he has only mild symptoms that are not even bad enough to warrant the comfort medication available under the protocol. He is drug seeking and nothing will be ordered at this time per the provider. Mr. Jones was very angry when he left the medical unit.” 

There was no physical assessment done, and no plan and no patient education documented. 

How Could the Note have been Written?

“38 year-old male arrives to the medical unit via wheelchair after reported seizure and fall from the top bunk. History includes substance use disorder (last use reported as three days ago on day of arrest). COWS and CIWA scores indicate mild withdrawal. Patient requests medication for pain at this time. 

[The physical examination is done and thoroughly documented, including vital signs measured, heart, lung, abdomen, neurological and body assessment for signs and symptoms of trauma. All evaluations are within expected parameters. There are no signs or symptoms of trauma.] 

Plan: continue to monitor patient per the COWS and CIWA protocols; Tylenol per Withdrawal Protocol PRN for discomfort; encourage hydration; low bunk profile. 

Patient education: Patient instructed in the usual/expected course of detoxification; reassurance provided; immediately report any further seizure activity to officers/medical staff for further evaluation and return to clinic; return to clinic as needed. Patient verbalized understanding of all. 

Patient ambulated without difficulty back to housing unit.”

In this example, facts are presented without words that reflect the author’s personal feelings and which could present a biased picture of the patient to other healthcare professionals. There was a documented plan that included parameters for monitoring and a low bunk profile, and patient education that included expectations, reassurance, and what to do if further seizure activity occurred.

 In your practice, I encourage you to always check your words. Are they unbiased? Do they convey the facts in a neutral way, and do they convey the situation without extraneous information unrelated to the current encounter? Are your actions indicative of a correctional nurse who unbiasedly examines and evaluates the patient for his/her/their presenting complaint?  I hope so! 

This post is taken from the February 2022 edition of The Correctional Nurse Newsletter.  If you haven’t already subscribed, I invite you to do so….there is no charge and your information will never to be given/sold to anyone else!