Charting...what to say? - page 3
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... Read More
0Apr 27, '13 by SunshineDaisyI was also taught not to use I...When I watch my preceptor document it's usually like "patient taught about xyz" or "doctor notified of patient's condition" or something like that.
0Apr 27, '13 by CreamsodaYup I always use "writer". But now that I think about it I dont know using "I" is wrong
0Apr 28, '13 by akulahawkRN, ASN, RN, EMT-P ProI'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."
1Apr 28, '13 by MatrixRn, BSNAt the end of the day you want to follow the policy of your facility.
6Apr 28, '13 by Julius Seizure, BSN, RNAfter 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.
0Apr 28, '13 by joanna73 GuideSame 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.
0Apr 28, '13 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.
0Apr 28, '13 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?
5Apr 28, '13 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..
7Apr 28, '13 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.
3Apr 28, '13 by netglowI 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.
0Apr 28, '13 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!