Charting...what to say? - page 2

by chrisrn24 | 10,468 Views | 44 Comments

Correct me if I am wrong but in charting you're not supposed to say "I," right? We have a new nurse who charts, for example, "I spoke with the patient about X." I learned to write "writer discussed X with patient" no personal... Read More


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    Quote from Janey496
    I was taught never to use "I" but I guess I couldn't really tell you why it's wrong. I definitely agree with the other poster who said EMR charting that has done away with narrative notes has definitely been a detriment to good charting. I'm considering writing narrative notes in my EMR anyway....but I wonder if its a good idea since I'd be the only one doing it. Nowadays everything can be a liability it seems.
    At my previous workplace, we never did narrative charting either. When I got a new job, narratives are expected x 2 in a 12 hour shift. It took me a good month to refine my narratives and get in a groove where I didn't have to think about what to write. I have had a lot of the residents tell me that they read our narratives to get the nurse's perspective on the patient's status, whether ordered procedures/specimen collections/outcomes to interventions were done during our shift, pain management, etc. I start out addressing the level of consciousness and mobility. Then, I move to the patient's status as it relates to the primary medical problems identified in the docs' notes. Example: COPD exacerbation, I give a short respiratory assessment and also indicate if it is improving/declining if I can. Any nursing observations are next, such as complaints addressed by nursing and not requiring a new MD intervention (such as nausea that is not new to the patient w/ Zofran already ordered). Then, I write about those items that the doc was notified for, with the docs name and time of notification, any new orders received, implementation of those orders, and outcome. Procedures/specimens during my shift come last, w/ a rhythm statement if I work the tele floor. This might seem like a lot, but the length of the note is about the same as this post.
    Sugar Magnolia likes this.
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    We use computer charting, but if I do write a note, I just write whatever I want to. Sometimes I will use "I" and nobody has ever said anything about it. If it isn't "I" then who is it?
    LaRN and macawake like this.
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    I was also taught to never use the first narrative. The objective of charting is that your observations are objective not personal and subjective. Proper documentation will save you in the event of a lawsuit...remember you maybe asked at anytime to defend what you have written and why.

    Altercations/interactions with families or patients are not to be from a personal point of view as that takes it from professional to point of view of patients behavior to a name throwing contest in the school yard. a nurse is to be objective at all times in her documentation.....It does matter, especially if you are called into a court of law.

    I could care less how the MD documents it his butt not mine....that what he gets the biog bucks for (any pays big bucks for in malpractice).

    Here are some excerpts from Purdue Owl about writing as a professional nurse.
    http://owl.english.purdue.edu/owl/owlprint/922/

    According to Purdue Owl.......

    Three General Rules

    Be Precise
    This may seem to go without saying, but you should remember that accuracy is important even beyond the obvious areas like medication administration and treatment procedure. Accurately reporting sequences of events, doctor’s orders, and patient concerns will protect you from scrutiny.

    Example: “Did dressing change.”

    If this is the entire record of you performing a dressing change for a patient, then exactly what you did is up to interpretation. A more precise version would be:

    “Performed dressing change, cleaned wound with NS and gauze, applied calcium alginate, covered with ABD, secured with silk tape. Patient tolerated well.”

    This revision provides a clear picture of every step of the procedure and explains use of all materials. (Note: even further explanation may be necessary to describe wound status and any changes or doctor notifications.)

    Be Objective
    Always try to remove personal emotions and opinions from the writing you do. Place yourself in a dispassionate mindset and record information, not feelings, hunches, or viewpoints.
    Example: “Patient acting crazy.”

    This statement relies on the nurse’s subjective opinion of the patient’s mental state. A better version would be:

    “Patient pacing back and forth, breathing fast, clenching fists, yelling ‘Don’t touch me!’ repeatedly.”
    This provides a clear picture of what actually happened during the incident, allowing the reader to draw his or her own conclusions.

    Remember Your Critical Audience
    Litigation and auditing are a fact of life in the medical field, and chances are good that readers of your writing will be actively looking for mistakes or inconsistencies. Scrupulous charting and reporting is the best way to satisfy such readers.

    Examples: “Did dressing change.” “Patient acting crazy.”

    Both of the examples in the above points could be used by a critical audience to have cause for correction or could be used negatively against you in court. The phrase “Did dressing change” details no necessity for specific materials, leaves room for doubt as to compliance with doctor-ordered treatments, and can provide space for accusations from expert witnesses. Writing “Patient acting crazy,” without quantifying statements and description of your actions, can be grounds for charges of negligence. Either one of these cases, in an extreme scenario, could be grounds for you to lose your license.

    Do not use the first person.
    In narrative charting, avoid the use of “I” and “me.” Instead of “I observed . . .” use “This nurse observed . . .” “I change the dressing daily,” becomes “Nursing changes the dressing daily.” This helps to maintain the impersonal tone discussed above.
    I went to Purdue so maybe I'm partial.....
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    I can give you a bad reason for avoiding the first-person voice: to avoid personal responsibility. This is generally gussied up as "sounding objective." It's a popular practice among lesser academics, healthcare workers, and IT support desks which is one reason why all the texts produced in such venues are barely readable.

    It's unnecessary even in those circles. Even the APA, one of the most godaawful style guides inflicted on a weary world, doesn't require it:

    http://owl.english.purdue.edu/owl/resource/560/15/

    Nonetheless my school and job require third-person constructions, so "this grad student/skilled nurse/case manager" uses both. And bides her time.

    Dina
    Spidey's mom likes this.
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    Esme, thanks for the excerpt. I love OWL too, although I didn't go to Purdue.

    The reason given was to "help maintain an impersonal tone." Hrmm. While the message of objectivity is good, I think that it can be done without using third person. I totally disagree with OWL's "improvement" from "I change the dressing daily" to "Nursing changes the dressing daily." WHO did the dressing change, when was it done? If taken to court, there is so much wrong with "Nursing changes the dressing daily," I don't know where to begin!
    prinsessa, macawake, anotherone, and 1 other like this.
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    That was not the best example....I just write....since I am doing the writing.

    Drsg changed...(then) what I observed, how I changed it (sterile etc), how I cleaned it/packed it/dressed it, what it looked like.

    For a patient being verbally assaultive.

    Patient shouting obscenities, "&*)^&%^$%*$(^&(&&*(" , loudly disturbing other patients in department. Patient states....."&**(&&%^%*(&)*^)*&_()*". Patient shouting verbal threats of physical violence to this nurse and other staff members by shouting....
    "()&_*&&*)^&^$%#!@!$&^&*_&_"

    while assisting patient with IV patient spit in this nurses face stating...."&*&^%^& ^&%^&%$^"

    Which Sounds better than...."the patient was calling me names and spit in my face."

    One sounds professional one sounds like a petulant child
    Last edit by Esme12 on Apr 27, '13
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    Quote from Esme12
    Patient shouting obscenities, "&*)^&%^$%*$(^&(&&*(" , loudly disturbing other patients in department. Patient states....."&**(&&%^%*(&)*^)*&_()*". Patient shouting verbal threats of physical violence to this nurse and other staff members by shouting....
    "()&_*&&*)^&^$%#!@!$&^&*_&_"

    while assisting patient with IV patient spit in this nurses face stating...."&*&^%^& ^&%^&%$^"

    Which Sounds better than...."the patient was calling me names and spit in my face."

    One sounds professional one sounds like a petulant child
    I get where you're trying to go with this but I'm not sure this is the best example, you changed far more than just the term "I" in this example. An objective way of charting this would be "patient expectorated in the direction of staff". Who was spit on is irrelevant from an objective standpoint, so whether you use "I" or "this Nurse" really doesn't matter, they are equally less objective ways of saying this.

    The term "this Nurse" is just a euphemism for "I", they're interchangable in terms of meaning, it just makes it sound clunky and is arguably poor grammar. The purpose of charting is to be precise, "I" means "I", "This Nurse" can mean "I" but it can also have other meanings, making it a less accurate, but no more objective, way of saying "I".

    When it comes to objective, boilerplate charting, H&P's are near the top of the scale, yet the term "I" is frequently used.

    I think the main problem is we've succumbed to the myth that speaking in third person adds objectivity and accuracy even though it doesn't. If I said "I don't like spinach" is that any less objective of a statement than "this person doesn't like spinach"? Same level of objectivity, just bad grammar.
    workingharder, Amnesty, Benedina, and 6 others like this.
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    I'd like to expand on Esme's post a bit and add that I always write the exact curse words yelled at me, in quotes of course, in the chart. Mostly to provide a complete and accurate account of events (the pt. did not say "asterisk asterisk asterisk", the pt. said "[insert expletive]), and partially out of the glee arising from putting curse words in an official document.

    As far as third-person narratives go, they sound more formal and professional. I am not a high school student writing a note, I am a health care professional documenting objective observations and care provided. "I-statements" are not objective statements.
    Janey496, nrsang97, and Esme12 like this.
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    I just discussed this with my husband - he's a police officer, and his narrative reports end up in courtrooms far more often than ours - and he uses "I" in all of his narratives. He was trained to do so. So I guess I'm on the fence. The legal system doesn't seem to have a problem with using "I." Perhaps we shouldn't either.
    kylee_adns, workingharder, macawake, and 1 other like this.
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    Even though I graduated from nursing school when we used leeches and herbs, I was always taught to write in the third person and referred to myself as "This LPN" because it was to be as objective vs subjective as possible.

    Ex: Received report from M. Ratched, RN, reviewed assessment, changes made per this LPN.

    What really happened? I had to follow Nurse Ratched who's shift assessment was simply done by clicking the "no changes" button and I don't think she even looked at this kid in the past few hours. I had to clean up her mess and fix everything before anymore harm was done to MY patient.
    Esme12 likes this.


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