Charting...what to say? - page 5

by chrisrn24 | 10,469 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


  1. 0
    Perhaps this depends on your training and facility policy. Using "I" is not incorrect, but we were trained not to use "I" in documentation and the staff at the facilities I have worked at don't use "I".
  2. 2
    i just read 5 pages of to I or not to I and all "I" can say is....wait they taught you charting in school? I got ripped off
    DiverseCity and netglow like this.
  3. 0
    I write in a patient centered format. And I was taught in school to stop charting, "pt blah this, or
    Pt used bathroom" that it goes without saying that you are talking about the patient.

    Sometimes I follow that rule, sometimes
    I don't. Right now, in my early baby nurse days, I take the nurses who I admire the most and see how they chart.

    Any thoughts?? Is charting "pt did xxxx" fairly redundant when you are only talking about one person? I can see if you were charting about multiple people where you would need clarity.
  4. 1
    Quote from FlorenceNtheMachine
    I write in a patient centered format. And I was taught in school to stop charting, "pt blah this, or
    Pt used bathroom" that it goes without saying that you are talking about the patient.

    Sometimes I follow that rule, sometimes
    I don't. Right now, in my early baby nurse days, I take the nurses who I admire the most and see how they chart.

    Any thoughts?? Is charting "pt did xxxx" fairly redundant when you are only talking about one person? I can see if you were charting about multiple people where you would need clarity.
    I think it is. I would just write "up to toilet" or "took pills whole with thickened water" not "patient up to toilet" etc.
    macawake likes this.
  5. 1
    I always use "this RN" (or something similar) and never "I" in my charting, however, I must say that I can't really come up with a good reason of not saying "I."

    I was taught in nursing school that it is a given that, unless specified, the subject of a sentence is the patient. For example "took pills with thickened water" would mean it was this patient, even though I often say "pt took pills..." One thing I always add to my note is how the patient tolerated a given task. For intense "pt. stood without difficulty and walked independently to bathroom with steady gait." (From an ER perspective, if we are going to be sending them home, it is particularly important to chart that they are walking "normally" for them.)
    macawake likes this.


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