How to refer to self when writing a nursing note

Nurses General Nursing

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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..

Specializes in Med/Surg, LTC/Geriatric.

I've been taught, and only ever used and seen "writer".

"Writer noted increased edema to left foot..."

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Specializes in Geriatric Nursing.

I just write RN after may name.

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Specializes in Cardiac Surgical ICU.

I just leave all of that out completely...for example: pt became tachycardic. MD notified. Received order to perform 12 lead.

Something like that.

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Specializes in Acute Care, Rehab, Palliative.

I refer to myself as "writer", it's what we were taught in school and it stuck.

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I just leave all of that out completely...for example: pt became tachycardic. MD notified. Received order to perform 12 lead.

Something like that.

I so exactly the same thing. Everyone knows who did the the notifying and received the orders because of the signature. The only time I specify anyone by name is if I didn't actually do or observe something myself but another nurse or the tech did it, then I will state the name and title of the person who performed a particular procedure or made the observation. The only other exception to this is when I am discharging a pt from the ED but I didn't actually take care of the pt, I will sign the electronic dispo, "this RN for d/c only."

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Specializes in Med/Surg, Ortho, ASC.
I've been taught, and only ever used and seen "writer".

"Writer noted increased edema to left foot..."

I wonder if this is a geographical difference, as in different trends in different areas? I've honestly never seen "writer" used until this thread.

I just avoid referring to myself and stick to the basics:

"Patient up to BR with assistance. MD notified of abnormal lab values."

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Specializes in ICU, ER.

I was taught to use "undersigned" if it isn't clear who I am refering to. Ex: "Pt. found on floor next to bed by J. Smith, CNA, Dr. L. Joness notified by undersigned." This makes it clear that the doctor was called ny me, and not the CNA.

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Specializes in LTC, Psych, Hospice.
I wonder if this is a geographical difference, as in different trends in different areas? I've honestly never seen "writer" used until this thread.

I just avoid referring to myself and stick to the basics:

"Patient up to BR with assistance. MD notified of abnormal lab values."

I agree. I will mention other stafff if they actually witnessed the event, then I will say "I" to make clear my part in the event. "Called to room by E. Nuff, CNA r/t pt on the floor. Assisted CNA to return pt to bed. I performed full head to toe assessment. MD contacted. Hospice Nurse, LPN"

Actually, the only time I've ever seen "writer" is from a couple of nurses I used to work with from Canada.

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I work in a clinic setting, so I'm sure its a bit different, but my docs hate to read drawn out entries, so I stick to the absolute minimum necessary. I was taught in nursing school to just write the facts, and the less I add to that the better. The only thing I am very careful about is writing "patient stated" entirely too much, just to be clear that I am not saying the pt has done x, y, z, just that the patient has said it, so I'm not held liable.

"Pt called stating Ambien was giving nightmares. Per Linda Skewn, MD, called Diphenhydramine in to Walmart Pharmacy 555-5555, pt aware. Jenn MyrtleBeach, LPN" (of course giving strengths and dosages as well)

I figure since I'm putting my name at the end, I dont need to say my name inside the note, I only say the names of others involved in the care if necessary so that I am not speaking of something that someone else did, that I cannot speak for personally for liability. CYA all over the place. We have one nurse who says "this nurse" and it sounds funny to me, but perhaps its just because I only see it with her (out of 50 or so nurses we have)

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Specializes in Med/Surg, LTC/Geriatric.
I agree. I will mention other stafff if they actually witnessed the event, then I will say "I" to make clear my part in the event. "Called to room by E. Nuff, CNA r/t pt on the floor. Assisted CNA to return pt to bed. I performed full head to toe assessment. MD contacted. Hospice Nurse, LPN"

Actually, the only time I've ever seen "writer" is from a couple of nurses I used to work with from Canada.

From Canada :)

And I would chart the above as "Called to room by CNA, r/t pt on the floor. Assisted CNA to return pt to bed. Writer performed full head to toe assessment. MD contacted. Julie Smith, LPN.

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we were taught that nursing notes were supposed to be third person and never to use "I" in the notes. Therefore, it is "writer." However, I rarely use that as it is possible to write effective, short, and factually correct notes without using it:

Pt presented with complaints of light-headedness and general malaise. BP: 90/60, P: 95. Accucheck obtained, BS: 7.8. Patient given...... and then sign it.

Or:

Pt found on floor in hallway. Assessment showed left leg externally rotated. Pt c/o severe pain, rating it 10/10, moaning, pale. BP...... Pt lifted with assistance of CNA and another RN to stretcher. Transported to.....

Why do you need to refer to yourself at all?

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Specializes in MSP, Informatics.

[iHow to refer to self when writing a nursing note][/i]

I just say The Queen.... then everyone knows its me. :jester:

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