From the Guidelines
To document a patient's propensity for anger in their medical chart, use objective, non-judgmental language that describes specific behaviors rather than making character assessments. When documenting, begin by noting observed behaviors such as "Patient demonstrated increased volume and rapid speech when discussing treatment options" or "Patient expressed frustration through clenched fists and abrupt movements during the examination" 1. Include direct quotes when relevant, document any triggers that preceded the anger response, and note the duration and resolution of the episode. Always document interventions attempted, such as de-escalation techniques used and their effectiveness.
Key Points to Consider
- Include any safety concerns for staff or the patient themselves
- Document any history of similar behaviors from previous encounters or reports from other healthcare providers
- Establish patterns of behavior that might indicate underlying conditions requiring treatment, such as an impulse control disorder
- Provide legal protection by demonstrating appropriate care was provided despite challenging interactions 1. Some studies suggest using screening tools to assess distress and unmet needs in patients, such as the BSI-18, DT, or ET, which can help identify underlying issues that may contribute to anger 1. However, when documenting anger specifically, focusing on behavioral observations and interventions is crucial.
From the Research
Documenting Patient Anger in Medical Charts
- There is no direct evidence from the provided studies to support the documentation of a patient's propensity for anger in their medical chart.
- The studies primarily focus on the treatment of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) using selective serotonin reuptake inhibitors (SSRIs) and trauma-focused psychotherapies 2, 3, 4, 5.
- However, it is essential to document any behavior or symptom that may impact patient care, including anger or irritability, as it can be a symptom of underlying conditions such as PTSD or MDD.
- When documenting patient anger, it is crucial to use objective language and focus on the specific behaviors or incidents that occurred, rather than making subjective judgments about the patient's character or personality.
- Healthcare providers should consider using standardized assessment tools or rating scales to evaluate patient symptoms, including anger or irritability, to ensure accurate and consistent documentation 3, 4.