Charting...what to say? - page 4

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

  1. Visit  MotherRN profile page
    0
    Quote from chrisrn24
    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.
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  3. Visit  joanna73 profile page
    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".
  4. Visit  puravidaLV profile page
    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.
  5. Visit  FlorenceNtheMachine profile page
    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.
  6. Visit  chrisrn24 profile page
    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.
  7. Visit  psu_213 profile page
    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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