narrative documentation and use of "this nurse"

[anon456]

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?

[Guest219794]

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.

That's just silly. The word "I" is not subjective. The phrase "I think" is subjective. Whoever taught you that did not understand the meanings of subjective and objective.

Subjective: "Patient is having a violent tantrum".

Objective: "Pt speaking loudly, kicking chairs, and throwing objects".

But the word "I" refers to hherrn, as does the phrase "this writer". They mean the same thing. It's just that the term "this writer" is goofy and cumbersome. It adds no clarity, it only adds volume.

Most of us, myself included, were just taught wrong. "Well, I learned it this way, so I teach it this way...."

Much of how we document is less clear than it would be if we just wrote in normal English. "Nursing home charge RN called for update on patient status". Well, who called who? (whom?)

Of course, I could write " The nursing home charge RN was called by this writer and was given a patient update". Accurate, but written poorly.

Or, I could just write "I called the nursing home and updated the charge RN on pt status"

It is short, concise and accurate.

I suggest writing in simple, unambiguous English. There is no advantage to the outdated convoluted way many of us were taught.

[meanmaryjean, DNP, RN]

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

I sometimes write 'Patient happy to see his favorite nurse' and 'Patient and I grooving out to Queen's Greatest Hits' in my narrative in my homecare documentation. No one has ever questioned it. Mostly because no one EVER reads it I suspect.

[Nonyvole, BSN, RN]

I write third person. "Patient started yelling at RN about 'I am going to mess you up' and was waving a knife. RN called a code V and PD responded..."

My name is on the chart, I can go back a year later and say "yes, he was waving a knife at me," and nobody has complained.

[ArlyleRN]

"This nurse" is okay to use so long as "This Nurse" refers to "This Nurse" entering the notation and not "This Nurse" sitting beside me or "This Nurse" standing in front of me, or god forbid "This Nurse" looking over my shoulder.

[Kooky Korky, BSN, RN]

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

I say "writer" noted whatever I saw, or took whatever action I took. It's shorter than "this nurse", still not just plain "I". I agree with your sentiment. Tradition.

[SierraBravo]

I refuse to use the term "this writer" or "this nurse" or anything to that effect in my notes. It irritates the living daylights out of me. Whenever I read those terms in a note, it's like nails down a chalkboard for me.

[Guest219794]

I write third person. "Patient started yelling at RN about 'I am going to mess you up' and was waving a knife. RN called a code V and PD responded..."

My name is on the chart, I can go back a year later and say "yes, he was waving a knife at me," and nobody has complained.

Which RN?

How would you word it if he waved a knife at a different RN?

[SleeepyRN]

Which RN?

How would you word it if he waved a knife at a different RN?

I agree. I definitely would not have worded it like that. The writer may be able to go back a year later and say, "yeah, I was talking about me." But progress notes are for others to get a clinical picture. It has to be clear to others, not simply the writer of the progress note.

[LadyFree28, BSN, LPN, RN]

I use "nursing" for the sake of brevity; I was taught that using "I" statements, especially when notes are meant to be objective was a no-no, both in my PN and BSN programs; there was a rationale that made sense; however, I'll admit that it went by the wayside; however it was learned from a legal "defensive documentation" course many moons ago to not use "I" statements.

[Idaho_nurse]

That's just silly. The word "I" is not subjective. The phrase "I think" is subjective. Whoever taught you that did not understand the meanings of subjective and objective.

Never said it was correct, just said it was what "I" was told, lol... its all silly to me. I just try to avoid it all together simply because it sounds stupid when you are trying to read it. I have recently started using simply "patient" or "nurse" instead of "I" or "this nurse" and change my wording to make read correct.

[joanna73, BSN, RN]

I have never seen "I" in patient documentation where I have worked.

We were instructed to use "writer" As in: "Writer discussed medications with patient in room" or "Writer observed....."