How to refer to self when writing a nursing note

[lashuna1028]

Whats the appropriate or professional way to refer to self while writing a nursing note? Do you say "this nurse" "writer" "me"...?? I see "this nurse" alot but it just seems weird to refer to self like that..

[Blackheartednurse]

I just write nurse.

[caliotter3]

"This nurse", "Licensed Nurse" or "Skilled Nurse".

[KarmaComesAround]

I write "this nurse" or "this RN".

[journey_bound]

I've only ever seen and written "writer," as in: "Pt was talking to self when writer entered room" Referring to yourself as the writer is the most grammatical (and logical in my opinion).

I wanted to add as an edit, reading "this nurse" has the potential to be taken wrong, in that you are might be referring to another nurse who was involved in the care somehow... It's ambiguous.

[Davey Do]

lashuna1028:

You've submitted a good question. I've not seen a formal rule on how the author of a piece of legal medical documentation should refer to themself.

It seems to me that referring to oneself in a first person pronoun "I" flows more gracefully, grammatically-speaking. This method also seems to be more personal. My name and title is added to the end of the submission, so there's no question as to who "I" is.

I 've never recieved any negative feedback on this method.

So, that's what this nurse does, lashuna1028.

Dave

[RedhairedNurse, BSN, RN]

When I type a nurses note and refer to myself, I just say "I"

For example: Dr Doolittle at bedside. I informed him of pts abnormal lab results, awaiting further orders..........MyName, RN.

I don't understand why people say "this nurse" and sign his or her name, why

not just say I ?

Now here is the same documentation saying it the other way -

Dr Doolittle at bedside. This nurse informed him of pts abnormal lab results, awaiting further orders...........MyName, RN

Which sounds better? I like the first one myself.

[RedhairedNurse, BSN, RN]

I've only ever seen and written "writer," as in: "Pt was talking to self when writer entered room" Referring to yourself as the writer is the most grammatical (and logical in my opinion).

I wanted to add as an edit, reading "this nurse" has the potential to be taken wrong, in that you are might be referring to another nurse who was involved in the care somehow... It's ambiguous.

When "writer" enters room? I get your point that you're the writer, but

this does not make any sense at all to me. I think the word writer has

more potential to be taken wrong than 'this nurse.'

[KarmaComesAround]

When I type a nurses note and refer to myself, I just say "I"

For example: Dr Doolittle at bedside. I informed him of pts abnormal lab results, awaiting further orders..........MyName, RN.

I don't understand why people say "this nurse" and sign his or her name, why

not just say I.

Guess it was just back to how taught in school or trained. Ex: Pt escorted down by this RN via WC in stable condition.---------My Name, RN. Does seem weird, now that asked or mentioned. Hmmm....shall I start using "I"....may try it out...:) Love this site for others' input and how they do things.

[JulieCVICURN, BSN, RN]

I just say "I". Charting is not an APA format paper for a class, it's just a narrative of what happened. It needs to be clear, concise, and state only facts. The fact is that I am the one who witnessed the event or participated in it, so I am the one writing about it. Who "I" is is clearly indicated by the timestamp (if computer charting) or your signature.

[RedhairedNurse, BSN, RN]

Pt escorted to xray with my assistance via wheelchair and remained in stable condition..........MyName, RN.

Actually, I would leave me out of this note all together, I guess depending on the situation, I would just say

Pt transported via wheelchair in stable condition............MyName, RN.

[GRUNGE]

I just write i. This nurse or even i kinda sounds redundent since we already know your the one writing the note from your signature. A lot of the time i just leave the noun out. For examle: Pt bs 40, administered 15ml d50ns. Pt new bs 156 at ......