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..

[sharkdiver]

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.

And from your user name I've got a pretty good idea what general area.......the legend lives on.....

I was taught to always used 3rd person in a written report & have always used "writer"....stems from my LEO training in a former life.......

[diane227, LPN, RN]

I usually use "I" but other methods mentioned are find as well. It just needs to sound professional.

[VivaLasViejas, ASN, RN]

I think the third-person narrative sounds stilted and I try to avoid referring to myself at all in my nurses' notes. However, there are times when I'll intervene in a crisis situation and I will document what "I" did and said, as well as what others who were directly involved said and did. (No names other than the patient whose chart I'm writing in; only titles and medical record numbers.)

I think it's necessary in any situation, but especially one that could go sideways, to use direct quotes when possible and to distinguish what I did from what everyone else did. I've never received any objection to my methods in over 13 years, but I have been told on more than one occasion that my documentation of an event kept the facility's butt out of a sling with the State......not to mention covering my own.

[JDZ344]

I'm just a NA, but we do chart. I never refer to myself at all.

[smartnurse1982]

While were at it,can we actually say "comfortable" in our notes? As in "noted resting comfortably in bed"

I always thought comfortable is subjective.(a lot of my patients can't talk)

If I'm wrong please let me know and I will start making changes.

[rn/writer, RN]

The old third person reference is from the days of objective news writing when the reporter was supposed to be like a fly on the wall, observing, but never entering the story. Ideally, news accounts should have given the readers the facts without any bias or influence on the part of the writers.

With the advent of infotainment, "feature" news, and slanted journalism, those days are long gone. Now, the third person reference sounds a bit odd and unnecessarily self-effacing.

Clarity is more important in charting than keeping oneself off the stage. In fact, some of the contortions people put themselves through to avoid using first person draw more attention to their presence, not less.

As shown in many of the good examples above, most narrative charting can be accomplished without the use of first person pronouns. But when they are needed, "I" or "me" or "my" are clear and decent words and I won't hesitate to use them. (All right, I will hesitate a little because I do remember the old teaching, but after a brief little blip, I'll write them with satisfaction.)