Notes in 3rd person style

Posted
by MunoRN MunoRN, RN Member Nurse

Specializes in Critical Care. Has 10 years experience.

We've been asked by our legal team why some of our nurses chart their notes in 3rd person ("This nurse notified the MD...").

Does anyone know of what the purpose of 3rd person narrative in nursing notes is? A rationale is preferable, but any reliable source that advocates using 3rd person would help as well.

Edited by MunoRN

roser13

roser13, ASN, RN

Specializes in Med/Surg, Ortho, ASC. Has 17 years experience. 6,504 Posts

Anxious to see the answers to this. We were all taught to chart this way and it can be incredibly awkward, but I cannot remember the rationale behind it.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 7,921 Posts

The only thing I could find was that it's considered a "formal" style, although the question our lawyers need an answer to is why that is a more effective way to communicate or why it's better for the patient.

Oh'Ello, BSN, RN

Specializes in Heme Onc. 226 Posts

Found this, which of course is more anecdotal than concrete rationale:

https://allnurses.com/general-nursing-discussion/why-do-nurses-652833.html

What the English minor said in that thread. I don't really chart in the first or third person, I just use nurse/person negative language. "Vancomycin and Zosyn administered per order" "Discussed Critical hemoglobin with xxx, PA-C, no intervention at this time". It's simply narrative and doesn't sound as stupid as the third person "nurse did this, nurse did that" nonsense.

Further: Including "self" into the note is just redundant... I'm charting it... I don't need to identify myself. My name is attached to charting. Stating whats going on and who else is involved seems to be enough.

Edited by Oh'Ello

Pangea Reunited, ASN, RN

Has 6 years experience. 1,547 Posts

I was taught that it keeps the focus of the note on the patient instead of the writer.

Pangea Reunited, ASN, RN

Has 6 years experience. 1,547 Posts

What the English minor said in that thread. I don't really chart in the first or third person, I just use nurse/person negative language. "Vancomycin and Zosyn administered per order" "Discussed Critical hemoglobin with xxx, PA-C, no intervention at this time". It's simply narrative and doesn't sound as stupid as the third person "nurse did this, nurse did that" nonsense.

Further: Including "self" into the note is just redundant... I'm charting it... I don't need to identify myself. My name is attached to charting. Stating whats going on and who else is involved seems to be enough.

How would you phrase it if someone threw an IV pole at you?

MunoRN, RN

Specializes in Critical Care. Has 10 years experience. 7,921 Posts

"Neutral" narration isn't really the problem, it's the use of "this nurse" that has gotten one of our nurses into a difficult position in court. It's being argued that it's not clear who exactly performed a certain action since "I" is the proper way to communicate what someone did in a narrative they are writing themselves, a neutral description is also defensible (antibiotics were given). This has also opened up an argument against the facility that we haven't adequately ensured our nursing staff has adequate comprehension of the english language. If the nurse can present some sort of rationale as to why 3rd person should be used then they should be fine, but we're not sure what that is.

Oh'Ello, BSN, RN

Specializes in Heme Onc. 226 Posts

"Neutral" narration isn't really the problem, it's the use of "this nurse" that has gotten one of our nurses into a difficult position in court. It's being argued that it's not clear who exactly performed a certain action since "I" is the proper way to communicate what someone did in a narrative they are writing themselves, a neutral description is also defensible (antibiotics were given). This has also opened up an argument against the facility that we haven't adequately ensured our nursing staff has adequate comprehension of the english language. If the nurse can present some sort of rationale as to why 3rd person should be used then they should be fine, but we're not sure what that is.

Yikes, whoops I'm out of my league here... I've never even read charting like that o_O

psu_213, BSN, RN

Specializes in Emergency, Telemetry, Transplant. Has 13 years experience. 3,878 Posts

I do have to admit, I occasionally do write notes that say "This RN called lab, spoke with Julie regarding delay in CBC results. Per Julie, machine had to be recalibrate and results will be available in the the next 15 minutes." I guess my rationale (other than "that is how I was oriented) is that sometimes I will write a note that says "Social worker Mary R. spoke with pt about transfer to psychiatric facility," and stating "this RN" when I write a note helps to clarify that I made the call. Then again, if I don't mention "this RN" nor a name, I would imagine that it is assumed :nailbiting: that I was the one who performed the action specified in the chart. For instance, I usually chart "Notified Dr. Smith of critical lab result, K = 6.1" without actually stating "but this RN."

In the end, I don't think it is necessary to chart in the third person, although I'm not sure I see the harm in it. To the OP, why is the legal team taking interest in this?

flutist

flutist, RN

197 Posts

I usually chart as writer. Example. Writer spoke with residents daughter who is concerned re abc.

Adele_Michal7, ASN, RN

Specializes in Pediatric. Has 5 years experience. 893 Posts

How would you phrase it if someone threw an IV pole at you?

Ouch!