narrative documentation and use of "this nurse"

Posted

I had a series of incidents yesterday where I had to provide some long narrative descriptions of patient behavior and interactions in a patient's chart. I am well-versed in how to remain objective and not make judgement statements. For example instead of writing "The patient was angry" I would say "the patient was pacing the room, waving his fist and throwing items." (these are all made up, by the way)

As I was typing my long note I started to get more and more annoyed by the language that seems to be our culture to use when making these long notes, especially when referring to myself and what actions or observations I made. For example "This RN observed the patient pacing the room and shaking his fist. . . " or "This nurse asked the patient what was bothering him" or "The patient kicked this nurse in the shin."

Why can't we just say "I observed the patient" or "I asked the patient" or "the patient kicked me" or whatever it is?

It is very clear to anyone who is reviewing the chart that I am the one writing the note. I am the one assigned to that patient, and I am the one who is electronically signed into the charting. How did this style of narrative start and what is the purpose?

meanmaryjean, DNP, RN

Specializes in NICU, ICU, PICU, Academia. Has 45 years experience. 7,899 Posts

That style of narrative comes from academic writing ('this writer' is in the throes of a doctoral program right now and cannot WAIT to stop with this stilted, unnatural language!). For charting, I would make it as simple and direct as possible. I write in first person in narrative notes.

anon456, BSN, RN

7 Articles; 1,144 Posts

I think I'm going to rebel and next time refer to myself in the first person.

SleeepyRN

1,076 Posts

I think I'm going to rebel and next time refer to myself in the first person.

I'm thinking of doing the same. I'm glad you posted this!

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 7,766 Posts

Keep in mind "this nurse" is also first person, so you're not really altering the perspective by using that term, just making it sound like bad english and adding an element of confusion. Most of the charting I see uses "I" when it's necessary but typically just omits pronouns all together, so maybe it's a regional thing.

anon456, BSN, RN

7 Articles; 1,144 Posts

I agree. Most of the time I try to avoid referring to myself at all. In this particular incident I had to refer to things that different people in the room said or did, and had to distinguish between myself and the other people (including another staff member).

Pangea Reunited, ASN, RN

Has 6 years experience. 1,547 Posts

I usually use "staff". It's easier to stomach than "this nurse".

Patient threw IV pole at staff (me!).

Idaho_nurse

Has 18 years experience. 66 Posts

The term "I" is just as confusing to me. It was explained to me by my superiors that the term "I" is considered subjective, and not objective. as in the term "patient states "yada yada"" as in subjective. but was able to put it into an SOAP note if I used the term "I" in the Subjective section of the narrative note... "I observed the patient resting in bed upon arrival" but that the term "I" does not belong in the Objective section of the note. Why? haha... I dont know. "I" just do as told, lol. I do slip up at times, and have not been called on it. I dont know if there is a difference when it comes to medicare charting or regular charting, I have just continued what I was taught to do, and write objective in the third person. It does annoy me though, when I go back and read my charting, so often times I will change my writing to make it is I dont have to use that third person, such as "client observed throwing clothing, and attempting to hit agency staff that was in the home" for example.

SleeepyRN

1,076 Posts

I hate hate hate "this nurse, this writer" and only use it when absolutely necessary.

I'm not saying this is correct, but below is what "this writer" does lol. I have yet to have anyone tell me I can't chart this way.

Ex. I charted on an unwitnessed "fall" the other day and simply wrote "observed patient sitting in front of wheel chair...." (She had had to use the BR but didn't use her call light,) so I also stated in the charting, "reinforced need to call for assistance...patient verbalized understanding..." Notice I'm avoiding pronouns altogether.

In this case the nursing supervisor was right there with me, so in the charting I wrote (not verbatim) "transferred patient to bed with assistance of on sift supervisor. Complete body assessment performed. No injuries noted...."

Whenever I use passive verbs, I'm referring to myself. "Observed," "reinforced..."

Occasionally to void confusion, I will state "this writer," but I limit the usage of such. Ex: CNA reported patient found lying on floor during rounds...this writer and CNA used mechanical lift to transfer patient to bed. Complete body check completed, no injuries noted, no c/o pain, neuro check implemented...

Edited by SleeepyRN

quiltynurse56, LPN, LVN

Specializes in LTC and Pediatrics. Has 3 years experience. 953 Posts

I think I'm going to rebel and next time refer to myself in the first person.

I am thinking of doing the same thing too

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 7,766 Posts

In high school it's not unusual to break academic/scientific writing down into overly-simplified rules, such as "never use I", just like you might learn that everything you write has to be five paragraphs, but it's not actually a rule in academic writing beyond that introductory stage. Some believe that academic writing should be in third person, but then use "this nurse", which is first person, "the nurse" would be third person when referring to yourself. I think the rule that a note should revolve around the patient not the nurse gets confused with first vs third person use. It's generally pretty rare, but when the nurse needs to clarify something they did, "I" is the correct term to use, "this nurse" is less clear and prone to misinterpretation, violating a basic rule of academic writing.

Should I Use "I"? - The Writing Center

Is it acceptable to use first person pronouns in scientific writing? | Editage Insights