Charting...what to say?

[chrisrn24]

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 tenses. Any thoughts?

[RCBR]

Don'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.

[TerpGal02, ASN]

I 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.

[SunshineDaisy, ASN, RN]

I 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.

[Creamsoda, ASN, RN]

Yup I always use "writer". But now that I think about it I dont know using "I" is wrong

[MaybeaNurse7]

Very informative stuff, thanks!

[akulahawkRN, ADN, RN, EMT-P]

I'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."

[MatrixRn]

At the end of the day you want to follow the policy of your facility.

[Julius Seizure]

After 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.

[joanna73, BSN, RN]

Same 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.

[FuturePsychNP]

The 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.

[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?

[macawake, MSN]

This 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..