Charting...what to say?

  1. 2 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?
  2. Visit  chrisrn24 profile page

    About chrisrn24

    Joined Oct '12; Posts: 947; Likes: 1,206.

    44 Comments so far...

  3. Visit  loriangel14 profile page
    1
    Yep I would do the same as you.
    Esme12 likes this.
  4. Visit  nrsang97 profile page
    1
    I have charted "RN spoke with pt about ...." Or "Writer observed pt get up oob w/o assist and reminded pt to use call light for assist."

    I have never used "I" in charting.
    Esme12 likes this.
  5. Visit  itsnowornever profile page
    7
    I'll put things like "pt educated about..." Or "xyz discussed with pt"

    Posting from my phone, ease forgive my fat thumbs!
    nursel56, macawake, Race Mom, and 4 others like this.
  6. Visit  BrandonLPN profile page
    4
    Quote from itsnowornever
    I'll put things like "pt educated about..." Or "xyz discussed with pt"

    Posting from my phone, ease forgive my fat thumbs!
    Me too.

    Using "this nurse" or "this writer" is better than "I", I suppose. But even the "this nurse" bit can be dome away with. Just chart "pt educated in incentive spirometry use" or "pt observed to be ambulating w/o assist." No need to put "I" or "this anything" anywhere.

    I've noticed a lot of my fellow nurses need to simplify and streamline their narrative charting. This is why I'll always be grateful I've had my years of experience with paper charting in LTC. Electronic flow sheet charting has lots of advantages. But, once all charting becomes paperless, I fear a well written nurses note will become a thing of the past.

    I've seen many RNs come to my facility from hospitals where all charting is of the "point and click a box" variety. They're great nurses, but many of them couldn't write a truly coherent nurses note at first. Really, I think all EMR charting erodes narrative charting skills.
    al586, nursel56, macawake, and 1 other like this.
  7. Visit  RNperdiem profile page
    4
    Generally I use the stiff form that avoids the use of I . Once in a while, an occasional "I" might slip into my charting. I wouldn't worry about it.
    I divide nursing documentation into "stuff that will actually help the patient" and "other/administrative stuff that is helps me keep my job" and more care is given to the former category. Correctly documented vital signs will guide patient care, the boilerplate narrative "call bell in reach, bed is low and locked..." is part of the other administrative required charting.
    AJJKRN, sssT, anotherone, and 1 other like this.
  8. Visit  CT Pixie profile page
    0
    I was also taught never to document *I*. My facility prefers we use 'this nurse' as opposed to 'this writer' because they want it showing that the nurse wrote the note. Silly, really because our computerized system documents with the writers name and credentials automatically and it can't be modified. So my documentation reads once I hit enter.."blah blah blah" CT Pixie, LPN.

    To me saying something like "pt educated about X" or "XYZ discussed with pt" doesn't really give the reader the identity of who educated or who discussed. I guess that's why my facility is a stickler about putting 'this nurse' with things like that.
  9. Visit  chrisrn24 profile page
    1
    Quote from CT Pixie
    I was also taught never to document *I*. My facility prefers we use 'this nurse' as opposed to 'this writer' because they want it showing that the nurse wrote the note. Silly, really because our computerized system documents with the writers name and credentials automatically and it can't be modified. So my documentation reads once I hit enter.."blah blah blah" CT Pixie, LPN.

    To me saying something like "pt educated about X" or "XYZ discussed with pt" doesn't really give the reader the identity of who educated or who discussed. I guess that's why my facility is a stickler about putting 'this nurse' with things like that.
    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!
    Esme12 likes this.
  10. Visit  dudette10 profile page
    13
    I use "I" all the time because it seems like a silly thing to use third person, based on tradition more than anything. The attendings at my facility use "I" all the time, as in "I have personally examined this patient, and I concur with [insert resident's name]. " Can someone give a good reason--or any reason at all--why "I" is verboten in nurse's charting?
    TeflonNurse, LaRN, kylee_adns, and 10 others like this.
  11. Visit  Janey496 profile page
    3
    I was taught never to use "I" but I guess I couldn't really tell you why it's wrong. I definitely agree with the other poster who said EMR charting that has done away with narrative notes has definitely been a detriment to good charting. I'm considering writing narrative notes in my EMR anyway....but I wonder if its a good idea since I'd be the only one doing it. Nowadays everything can be a liability it seems.
    LaRN, Esme12, and netglow like this.
  12. Visit  dudette10 profile page
    1
    Quote from Janey496
    I was taught never to use "I" but I guess I couldn't really tell you why it's wrong. I definitely agree with the other poster who said EMR charting that has done away with narrative notes has definitely been a detriment to good charting. I'm considering writing narrative notes in my EMR anyway....but I wonder if its a good idea since I'd be the only one doing it. Nowadays everything can be a liability it seems.
    At my previous workplace, we never did narrative charting either. When I got a new job, narratives are expected x 2 in a 12 hour shift. It took me a good month to refine my narratives and get in a groove where I didn't have to think about what to write. I have had a lot of the residents tell me that they read our narratives to get the nurse's perspective on the patient's status, whether ordered procedures/specimen collections/outcomes to interventions were done during our shift, pain management, etc. I start out addressing the level of consciousness and mobility. Then, I move to the patient's status as it relates to the primary medical problems identified in the docs' notes. Example: COPD exacerbation, I give a short respiratory assessment and also indicate if it is improving/declining if I can. Any nursing observations are next, such as complaints addressed by nursing and not requiring a new MD intervention (such as nausea that is not new to the patient w/ Zofran already ordered). Then, I write about those items that the doc was notified for, with the docs name and time of notification, any new orders received, implementation of those orders, and outcome. Procedures/specimens during my shift come last, w/ a rhythm statement if I work the tele floor. This might seem like a lot, but the length of the note is about the same as this post.
    Sugar Magnolia likes this.
  13. Visit  applewhitern profile page
    2
    We use computer charting, but if I do write a note, I just write whatever I want to. Sometimes I will use "I" and nobody has ever said anything about it. If it isn't "I" then who is it?
    LaRN and macawake like this.
  14. Visit  Esme12 profile page
    6
    I was also taught to never use the first narrative. The objective of charting is that your observations are objective not personal and subjective. Proper documentation will save you in the event of a lawsuit...remember you maybe asked at anytime to defend what you have written and why.

    Altercations/interactions with families or patients are not to be from a personal point of view as that takes it from professional to point of view of patients behavior to a name throwing contest in the school yard. a nurse is to be objective at all times in her documentation.....It does matter, especially if you are called into a court of law.

    I could care less how the MD documents it his butt not mine....that what he gets the biog bucks for (any pays big bucks for in malpractice).

    Here are some excerpts from Purdue Owl about writing as a professional nurse.
    http://owl.english.purdue.edu/owl/owlprint/922/

    According to Purdue Owl.......

    Three General Rules

    Be Precise
    This may seem to go without saying, but you should remember that accuracy is important even beyond the obvious areas like medication administration and treatment procedure. Accurately reporting sequences of events, doctor’s orders, and patient concerns will protect you from scrutiny.

    Example: “Did dressing change.”

    If this is the entire record of you performing a dressing change for a patient, then exactly what you did is up to interpretation. A more precise version would be:

    “Performed dressing change, cleaned wound with NS and gauze, applied calcium alginate, covered with ABD, secured with silk tape. Patient tolerated well.”

    This revision provides a clear picture of every step of the procedure and explains use of all materials. (Note: even further explanation may be necessary to describe wound status and any changes or doctor notifications.)

    Be Objective
    Always try to remove personal emotions and opinions from the writing you do. Place yourself in a dispassionate mindset and record information, not feelings, hunches, or viewpoints.
    Example: “Patient acting crazy.”

    This statement relies on the nurse’s subjective opinion of the patient’s mental state. A better version would be:

    “Patient pacing back and forth, breathing fast, clenching fists, yelling ‘Don’t touch me!’ repeatedly.”
    This provides a clear picture of what actually happened during the incident, allowing the reader to draw his or her own conclusions.

    Remember Your Critical Audience
    Litigation and auditing are a fact of life in the medical field, and chances are good that readers of your writing will be actively looking for mistakes or inconsistencies. Scrupulous charting and reporting is the best way to satisfy such readers.

    Examples: “Did dressing change.” “Patient acting crazy.”

    Both of the examples in the above points could be used by a critical audience to have cause for correction or could be used negatively against you in court. The phrase “Did dressing change” details no necessity for specific materials, leaves room for doubt as to compliance with doctor-ordered treatments, and can provide space for accusations from expert witnesses. Writing “Patient acting crazy,” without quantifying statements and description of your actions, can be grounds for charges of negligence. Either one of these cases, in an extreme scenario, could be grounds for you to lose your license.

    Do not use the first person.
    In narrative charting, avoid the use of “I” and “me.” Instead of “I observed . . .” use “This nurse observed . . .” “I change the dressing daily,” becomes “Nursing changes the dressing daily.” This helps to maintain the impersonal tone discussed above.
    I went to Purdue so maybe I'm partial.....


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