Charting...what to say? - Page 4Register Today!
- Apr 28 by Janey496After thinking about the fact that doctors and police officers are "allowed" and even taught to write by saying "I"....well it seems to me like perhaps some of the reason that nurses/social work/etc are taught to write "objectively" is because, to be (maybe) unfairly blunt, who really cares what we think? While of course, WE know that isn't true, it is a pervasive attitude, isn't it? Am I the only one told that when I call a dr, they don't want to know my opinion, they just want to know the facts? Well what else would I be telling them? I think the fact that nurses chart in third person and drs in first person is kind of telling.
NOT saying that charting in third person is wrong. I just think that's probably part of how it came about.
- Apr 28 by joanna73Same as others:
"Writer observed x...."
"RN spoke with resident re: medication use..."
Or, Resident states, "I can't sleep because..."
I refrain from using "I" in my charting.
- Apr 28 by FuturePsychNPThe thing I don't like about medical documentation is that everyone wants sentence fragments. At any rate, I bet I have typed the following many thousand times; "Patient asleep. No physical distress noted." I have to enter something every two hours so when they're asleep that's it.
- Apr 28 by NurseDirtyBird@Janey496: Interesting point of view. Maybe also something to do with the fact nursing has traditionally been a female profession? Nobody's cared what women think until fairly recently in the grand scheme of things.
Or possibly we've been trained to write as objectively as possible in order to appear like we know what we're talking about, because otherwise nobody would take the "little nurses" seriously?
- Apr 28 by macawakeThis writer < = > this nurse < = > I
I don't see how using one or the other makes the chart more objective or subjective. It's what we write in addition that decides whether the charting is/seems professional or not.
Most of the time I will chart along the lines of "patient educated about...". On the rare occasion that I chart someone else's actions, I will write: "Dr B.R. Oken-Fingers educated patient about...".
I will occasionally write I, never this nurse or writer. Maybe it's just me, but I means accountability. To me this nurse sounds like I'm trying to distance myself from the text.
I was taught to refer to myself as "this writer" in nursing school but for some reason I never developed the habit..
- Apr 28 by AJPVI use "I" all the time. Our facility doesn't have a policy about this. Stating, "This writer educated pt x about y," does NOT magically turn your statement from first person into third person. It is simply a rhetorical tactic that fails to do so. To me, "I" is the clearest way of saying that "I" did something. I'm not trying to hide anything; "I" did it. If you have questions about what "I" did, then come ask ME, not a mysterious undefined third person. I have a hard time believing that a jury would take offense to this. It seems much more likely that they will judge me based on my nursing competence rather than on whether I chose to write my notes using archaic form instead of straight-forward modern english.
- Apr 28 by AmnestyI'm curious what my nursing school will teach us about this. I can already tell that what I'm going to do is whatever they tell me to as long as I'm in school, and then whatever policy says wherever I work. If there's no specific policy, I'll do it from my point of view. I'm not an omnipotent being observing the situation objectively from above xP. I'm a human being in the room and it's my job to write down what I saw, but in an objective way. Clarification is key here. Passive voice vs. active voice and third person vs. first person, none of that really makes a difference in the content. Keeping emotion out of it and keeping it professional makes all the difference. If third person helps nurses do that, power to them!
- Apr 28 by MotherRNQuote from chrisrn24I was taught that you only chart what you actually did yourself, or else it isn't legal. Charting something you observed would be okay. But still, we sign our names at the end of the documentation so it really isn't necessary to say "This nurse" etc...or at least to me it's redundant.That is why I use "writer" in some instances, because it really isn't clear all the time who did it. Did the aide educate Mr X on using the call light properly or educating him on why he needs to ask for assistance for ambulating. But I do see times where "this writer/nurse is not needed."
The nurse at my work that writes "I" is an awful charter. Writing "I" is the least of her worries!