Know what to document after an assault
March 1, 2001 less than 1 minute read
Know what to document after an assault
There are important items to document after an assault to prevent future incidents and learn from the current one, urges Betty Wendt Mayer, RN, MSN, ARNP, an ED nurse practitioner at Florida Emergency Physicians in Maitland. Mayer recommends documenting the following facts after an assault:
- The timing, setting, and circumstances that preceded the incident. For example: "Subject pacing in the waiting room for approximately 15 minutes, crying, has odor of alcohol, threatening triage nurse with leaving without being seen, etc."
- What the observer of above behavior did to de-escalate at the times. "Nurse X explained the triage procedure to patient at 10:10 a.m., rechecked vital signs at 10:30 a.m. Patient’s manner did/did not alter."
- The dialogue between the perpetrator and the victim or other staff members, quoted exactly.
- If, when, and who the observing staff member notified when violence threat was suspected or actuated. For example, Nurse X "called the charge nurse and hospital security at 11 a.m."
- Because research also shows many perpetrators are "frequent flyers," include documentation of verbal threats or violent incidents in the patient chart to give the caregivers a heads-up the next time.
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