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..

[talaxandra]

I've only seen allied health use "writer" and it always strikes me as odd, though I'm sure some of that is just because I see it so rarely.

I had frequently noted pronoun loss in health care documentation but, until a narrative I wrote was analysed in a publication, I had never realised how often health care happens without agency. For this reason, when my intervention needs to be identifiable (eg "I spoke at length with Mr X about his diagnosis, and gave him printed information from [source]" I use personal pronouns: me, I, myself.

I've recently been reading Coronial summaries online - they're fascinating and also a little frightening. In addition to making me more conscious of my assessment and documentation, the experience has also reinforced that I want to be able to securely state whether or not I did something. I sign for meds and fluids, dressings and line changes etc, but if there's been a prolonged discussion with a distressed family member, I want to be able to record what I said. If anyone's interested, this case is what reinforced that for me.

[turnforthenurse, MSN, NP]

I never say "I" or anything like that. I recently charted that I d/c'd a catheter and this is what I wrote:

"D/c'd urinary catheter per order. Aspirated 10cc of water from balloon. Catheter tip intact. Pt tolerated catheter removal well. Instructed to notify nurse or support of first void. Pt resting comfortably in bed with call light within reach. Family @ BS. ---- Name, Title."

[carolmaccas66, BSN, RN]

You can say 'scribe', as in "patient told scribe that she had pain". That way if you happen to be talking re another nurse, the person reading the NN doesn't get confused. Sometimes I have said 'this nurse' - just check with your facility what is acceptable as everywhere is different. Good question BTW as this is part of legalities how you write NN's.

[llg, PhD, RN]

I'm old enough to have learned paperwork back in the day before computers. Everything was charted written out long-hand ... and it was important to keep the notes as short as possible so that the could be easily read. Long notes = poor communication in most cases.

Extra words such as "the writer" and "the undersigned" were therefore eliminated. I've worked in 6 different states in different parts of the country and have never seen the used extensively in a system that relies on paper documentation for daily routine charting.

"Pt. ambulated x 2 without distrss. Changed abdomenal dressing x 1. Wound drainage blah blah blah..." No personal reference needed for clear communication. If necessary, I would use the simple "I" or "me" -- but that is rarely necessary.

[HeartsOpenWide, RN]

Unless I am writing something that some one else did (.i.e. SVE by MD: 8cm, 0 station, 100%) it seems implied that I did it: 0130: Massaged fundus to firm, nickle sized clot expelled, VSS; educated patient on lochia amount, color, and fundal position; pt states understanding. HeartsOpenWide RN.

[talaxandra]

Whereas I'd be more likely to write:

Ambulated with assistance x 2 - L) sided neglect is still present but reduced since yesterday.

Abdominal wound re-dressed per wound care chart; slightly more slough noted today, otherwise unchanged. ~ 100ml of clear, straw-coloured fluid drained from Redivac...

- still no personal pronouns but a little more detail. We still paper document here - longhand all the way!

[llg, PhD, RN]

Whereas I'd be more likely to write:

- still no personal pronouns but a little more detail. We still paper document here - longhand all the way!

Actually, I would include more details too. I was just trying to illustrate the non-use of pronouns or other words to refer to myself.

[GM2RN]

I've only seen allied health use "writer" and it always strikes me as odd, though I'm sure some of that is just because I see it so rarely.

I had frequently noted pronoun loss in health care documentation but, until a narrative I wrote was analysed in a publication, I had never realised how often health care happens without agency. For this reason, when my intervention needs to be identifiable (eg "I spoke at length with Mr X about his diagnosis, and gave him printed information from [source]" I use personal pronouns: me, I, myself.

I've recently been reading Coronial summaries online - they're fascinating and also a little frightening. In addition to making me more conscious of my assessment and documentation, the experience has also reinforced that I want to be able to securely state whether or not I did something. I sign for meds and fluids, dressings and line changes etc, but if there's been a prolonged discussion with a distressed family member, I want to be able to record what I said. If anyone's interested, this case is what reinforced that for me.

I only got through about half of the case you refer to but I found it quite interesting.

With regard to this discussion, my opinion is that it is unnecessary to use "I" or "writer" or any other such term at all to identify myself in my notes since it is assumed that the person writing the notes has done or oberserved what is being described. The only two exceptions to this that I find to be necessary are if I'm relating what the patient has said to me, in which case I say "pt stated...," or if a tech, another nurse, a doctor, etc., did or said something, then I specify who did, said, or observed what I'm writing about.

Referencing the case that you refer to above, I see many places where documentation by both nurses and doctors could and should have been more thorough as to what actually took place, but I honestly don't see that it would have made difference had they referred to themselves with pronouns or other such identification. Further, I believe this is evidenced by the fact that the coroner seems to have assumed that each writer was the person doing the care at each writing, unless otherwise specified. So this very intersting case has not changed my opinion about how I document and I'm comfortable doing this way. I will say, however, that after reading this I will be attempting to make sure my documentaion is more thorough in terms of recording as much as I can about what actually took place.

[Not_A_Hat_Person, RN]

I use "this nurse." For example, "Patient complained of a headache. Rated pain 4 on a 0-10 scale. This nurse administered PRN APAP. Will monitor for effect. Not_A_Hat_Person RN"

[leslie :-D]

I've recently been reading Coronial summaries online - they're fascinating and also a little frightening. In addition to making me more conscious of my assessment and documentation, the experience has also reinforced that I want to be able to securely state whether or not I did something. I sign for meds and fluids, dressings and line changes etc, but if there's been a prolonged discussion with a distressed family member, I want to be able to record what I said. If anyone's interested, this case is what reinforced that for me.

wow...i just finished reading the woo inquest.

while all involved were strongly vindicated, it really does give pause to the importance of meticulous documentation.

seriously, if circumstances had been anything than what they were, a couple of those nurses could have definitely been incriminated.

now to get mrs. woo buried. ((

leslie

[BluegrassRN]

I used to use "this RN" as I was taught in school...until I noticed that physicians, social workers, PT/OT, counselors, and pharmacists all use *I* when they need to refer to themselves in their documentation: H&Ps, notes, assessments...they all use pronouns. What makes us think we need to do it differently? The use of third person seems outdated at best, and completely and utterly idiotic at worst.

I typically do not need to refer to myself, but there has been a rare occasion where it is necessary. For example, once I was documenting a violent episode where there were several people in the room, we were trying to calm an agitated patient, the patient eventually lost complete control of himself and we ended up taking him down and placing him in four point leather restraints. It was impossible to succinctly but thoroughly document the event without referring to myself (who told the patient what, who gave what med, who applied restraints, etc). In such an instant, I will simply use *I* when referring to myself.

[JSTARZ]

hmm...honestly "I" never use any of that. I just clearly state what happened and what was done. The time stamp tells who the "writer" is.

example:

"Educated client on importance of splinting incision while coughing, use of incentive spirometery, and deep breathing. Client verbalized understanding. Assisted client with turning and ambulation. My Name,BSN, RN"

"Physician contacted regarding am labs, no orders given. My Name,BSN,RN"

"Client refused lunch stating, "I don't want to eat that" Educated client on importance of following dietary recommendations. Client verbalized understanding and consumed 75% of tray. My Name, BSN,RN"

Ive never had an issue. thats my 0.02 cents. But to each his own.