Charting...what to say?

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AJPV

366 Posts

I 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.

netglow, ASN, RN

4,412 Posts

I agree with all those who think this whole thing is kinda silly.

You are signing whether in writing or e-signing when you chart, so you don't need to identify yourself because you are already identified.... as netglow, RN.

Amnesty

168 Posts

I'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!

MotherRN

192 Posts

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!

I 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.

joanna73, BSN, RN

4,767 Posts

Specializes in geriatrics.

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".

puravidaLV

396 Posts

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

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.

chrisrn24

905 Posts

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.

psu_213, BSN, RN

3,878 Posts

Specializes in Emergency, Telemetry, Transplant.

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.)

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