Documenting Difficult or Escalating Behaviour: Objective Language for Nurses and PAB/PSW
Labels like "aggressive" or "uncooperative" feel like documentation but say very little. A reader needs to know what the person did and said, what led up to it and how staff responded.
The short answer
Describe the behaviour instead of labelling it, quote key statements, record what happened before and after, list the steps staff took to help and keep people safe, and note who was informed. Canadian Nurses Protective Society (CNPS) guidance gives the example of writing "speech was slurred" instead of "client was drunk." Titles for support workers vary by province (PSW, PAB, HCA and others); the same principles apply.
Antecedent, behaviour, response
- Before: what was happening just before (a care task, a noise, a conversation, pain, a visitor).
- Behaviour: what the person said and did, in observable terms, including volume, distance, gestures and quoted words.
- Response: what staff did, in order, and how the person reacted.
- After: how the situation ended, any injury, and any follow-up.
Replace labels with descriptions
| Label | Description |
|---|---|
| Aggressive | Raised voice, said, "Get out of my room," pushed the tray table toward staff. |
| Non-compliant | Declined morning medication; stated, "I don't want that one." Risks discussed. |
| Manipulative | Describe what was asked for and what was said, without assuming motive. |
| Combative | Swung right arm toward staff while being repositioned; stepped back; no contact made. |
CNPS guidance says it is not acceptable to document a client as "non-compliant"; record what was refused and the information given.
Example (fictional resident)
Note
0715: While PSW prepared Resident R for a shower, resident stated loudly, "I won't go in there. Leave me alone." Stepped away from the bathroom door, hands clenched, did not strike or touch staff. PSW stopped and stepped back, spoke quietly, offered a later shower. Resident stated, "Maybe after breakfast." Nurse informed at 0720. Resident ate breakfast, accepted shower at 0950 with no distress. No injuries to resident or staff. Care plan updated to offer shower later in the morning.
Safety, injuries and reporting
If anyone was hurt or threatened, record injuries factually, the first aid or assessment given, and who was notified. Workplace violence reporting and any occupational health process are separate from the chart and follow your employer's policy and applicable law. If restraint or sedation was used, use the separate documentation required for it.
What to avoid
- Judgmental labels and assumptions about motive.
- Unsupported words such as "always" or "never."
- Diagnoses you have not been authorized to make, such as "psychotic."
- Comments about colleagues or staffing in the chart.
- Sarcasm or unprofessional language. Records may be read by the patient.
Template
Time: ___ What happened just before: ___ What the person said and did (quote): ___ What staff did, in order: ___ How the person responded: ___ Injuries or damage: ___ Notified (who, when): ___ Plan to prevent or reduce recurrence: ___
Where Fiabita fits
Fiabita's "Clean up my note" tool can help you reword rough notes into clearer, more objective language, and its SBAR handoff and incident-report tools ask guided questions so fewer details get lost under pressure. The output is a draft: you remain responsible for what goes into the record, and it does not check compliance with your regulator or employer. Do not enter information that could identify a real patient, and follow your workplace policy on which tools may be used.
FAQ
Q: Can I describe how it made me feel?
Keep it out of the clinical record. If you feel unsafe, use your employer's reporting and support processes.
Q: Should PSWs and PABs chart this too?
Support workers document what they observe and do within their role. Follow your employer's policy on who charts what and who must be informed.
Q: What if the person has dementia or a mental health condition?
Describe the behaviour and the response. Do not add a diagnosis unless it is already established and relevant, and follow the care plan.
Sources and further reading
- CNPS: Documentation for Nurses (guidelines)
- CNPS InfoLAW: Quality Documentation, Your Best Defence
- College of Nurses of Ontario: Documentation practice standard
Always check the current version of each source and your own regulator's standards; links and wording can change.