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!
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.