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?

[loriangel14, RN]

Yep I would do the same as you.

[nrsang97, BSN, RN]

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.

[itsnowornever, BSN, RN]

I'll put things like "pt educated about..." Or "xyz discussed with pt"

Posting from my phone, ease forgive my fat thumbs! :)

[BrandonLPN, LPN]

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.

[RNperdiem, RN]

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.

[CT Pixie, BSN, RN]

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.

[chrisrn24]

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!

[dudette10, MSN, RN]

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?

[Julius Seizure]

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.

[dudette10, MSN, RN]

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.

[applewhitern, BSN, RN]

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?