Charting...what to say? - page 3
by chrisrn24 | 10,464 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
- 3Apr 27, '13 by MunoRNWhat makes a statement less objective is clarifying something was done to you rather than someone, such as saying the patient spit in "this Nurses" face rather than just saying the patient spit in the direction of staff. Whether you use "my" or "this Nurse's" face makes absolutely no difference in terms of the objectivity of the statement.
- 4Apr 27, '13 by Esme12, BSN, RN Senior ModeratorQuote from NurseDirtyBirdAgreed.....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.
I always quote the patient as well...verbatim. I too get some back handed third grade giggle factor at charting swear words. However, profanity is against the TOS.......and a mix of letters and symbols is also against the TOS....I used all symbols in quotes intending to mean....the quoted expletives.
I will chart "SPIT" for to me that is intentional meanness, malfeasance, intent to harm........where expectorate is providing a specimen or clearing phlegm in the proper container or tissue and implies cooperation and manners. Like apples and oranges...they are both fruit but are completely different flavors.
I realize that police officers use first place in their reports as I have spent plenty of time in court, as an ED nurse an mandated reporter of ETOH in my home/original state, as well as a sexual assault/SANE nurse.
I was taught by medical legal experts and in my original program and additional legal/nursing type that referring to yourself in the first person isn't professional and negates you objectivity (for nurses). It has served my well for 34 years.....I guess you can't teach an old dog new tricks.
Each nurse decides whether or not to follow their schooling or practices (usual and customary) and what another reasonable and prudent nurse would do/say/document.
For me? This nurse will follow the recommended guidelines.
Are there laws that say you can't chart in the first person? No. Whether or not you "should" is up to the individual or facility policy.Last edit by Esme12 on Apr 27, '13
- 4Apr 27, '13 by RCBRDon't get too hung up on the "I" thing. There are much worse charting sins you can commit. Take your cue from physician notes; they use "I" all the time, as pointed by another poster here. The issue of objectivity is non-sense. Using the passive voice (dressing was changed) instead of the active voice (I changed the dressing) changes nothing substantively, only stylistically. You can only chart what you did, not someone else's work, so saying "dressing was changed" means exactly "I changed the dressing". The greatest sin in narrative charting is double charting, repeating what is already recorded in the flowsheets, such as A&Ox4, SR 70s, 4L O2 NC, VSS, etc. You should also avoid the "will continue to monitor" at the end. Of course you will continue to monitor, that is the core of your job! Writing a shift summary note does not mean you are abandoning your patient.
- 0Apr 27, '13 by TerpGal02, ADN, RNI use "this writer" also. I have found most social work people use it too. When I worked in the community all the staff shortened this writer to TW. I now work inpt psych and we still do paper nurses notes and its taken some getting used to to write out this writer rather than TW.
- 0Apr 28, '13 by akulahawkRN, ASN, RN, EMT-PI've been doing charting in some way, shape, or form for nearly 10 years. Mostly I don't write in first or third person... because it's assumed that I am the one doing the activity. If the patient is doing/saying something toward me specifically, then I'll typically note "author" to denote to whom the resultant issue was directed, if it's clinically indicated to do so. Otherwise, I'll simply chart about the patient and what was observed/performed/adjusted. I'll also note who I received report from, who I have contacted, and given report to specifically as it relates to the patient.
Also where I currently am at, the EMR system has a bunch of boilerplate narratives. I take that very bare-bones narrative and expand upon it greatly, and as necessary for that particular patient. How much time does it take for me to write the expanded narrative that I use? About 3 minutes, as I also have a boilerplate narrative in my head for what needs to be added.
I was also taught to be as descriptive as necessary to paint a good picture of the patient in mind of the audience. It's pretty simple... read the note, read the chart, and now you, the audience has a clearer picture about the patient, beyond the "data."