Notes in 3rd person style

canigraduate · Jul 2, 2015

I was taught that it is common practice and industry standard to use third person. The rationale I was given is that it is formal and necessary for legal language, in case of a suit. I find it ironic that a lawyer is questioning it.

I was taught this in nursing school and in a risk management presentation during onboarding in a hospital in the Southeast.

MunoRN, RN · Jul 2, 2015

I was taught that it is common practice and industry standard to use third person. The rationale I was given is that it is formal and necessary for legal language, in case of a suit. I find it ironic that a lawyer is questioning it.
I was taught this in nursing school and in a risk management presentation during onboarding in a hospital in the Southeast.

I'm wondering if it's a regional thing because it's something I've rarely ever seen and I've never once seen in a Physicians note, H&P, Op report, etc.

Any idea why it's considered necessary for legal language in areas where it is used more often?

TriciaJ, RN · Jul 2, 2015

I agree with previous posters. The reason to avoid "I" statements is because then "I" becomes the subject, instead of the note being patient-centered. Substituting "this RN" or "this writer" still makes it about the writer, not the patient. Instead of writing "this nurse informed the physician" it's better to say "the physician was informed". Just like "order was received" "medication was administered" "patient was given explanation". It feels awkward at first, but really important to not make the chart about you.

If questioned by a lawyer about this practice, be aware that anyone trying malpractice cases should be familiar with how medical records are written. The exchange mentioned in a previous post was just the lawyer's attempt to rattle and discredit the witness. When asked about medical chart format vs standard English, just remind all concerned that the chart is about the patient, third person format is standard healthcare practice and chart notes are primarily for the purpose of communicating with other healthcare professionals. (At least that's the ostensible reason; we all know the real one.)

canigraduate · Jul 2, 2015

I'm wondering if it's a regional thing because it's something I've rarely ever seen and I've never once seen in a Physicians note, H&P, Op report, etc.
Any idea why it's considered necessary for legal language in areas where it is used more often?

Well, you wouldn't see "This nurse" in a doc's notes. In the doc notes I've seen, they're in third person. "Patient is a well nourished 63-year old male who presents with complaints of chest pain and shortness of breath," for example.

I don't have any Op reports handy and my memory is faded, so I'll have to take your word on that, although I think the ones I've read have all been in third person without pronoun usage.

I was taught that it is necessary to use third person to keep the language from being confusing, so that the focus of the charting is on the patient. It was meant to clarify, not obfuscate.

I would turn it around on the lawyer and imply that their job knowledge is unsound if they did not know this already. Perhaps you should consult risk management or a malpractice insurance company.

Malpractice insurance lawyers would definitely be able to help you out with this one.

CopperEmerald · Jul 2, 2015

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

"Patient threw IV pole at this nurse"? Haha :dead:

jadelpn, LPN, EMT-B · Jul 2, 2015

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.

Because most EMR's have checkboxes. And most nurses are discouraged from elaborating.

canigraduate · Jul 2, 2015

Maybe it's an APA thing.

NGYSUN, BSN, MSN, RN · Jul 2, 2015

I have read many Drs notes and have observed that when describing a pt they usually state 'Pt is a 50yr old male, who lives at home. Had nausea and vomiting for three days and decided to come to the ER'

Then while explaining their plan of care either daily or whatever usually sounds like this

'Continue I.V fluids until evaluated by nephrology in am.

Continue antbx....'

Then for most surgeons, they report their operations with the first person, for example.... 'I made a 3cm cut across the xyz and I proceeded to irritating site with abc. I closed incision with dfg'

IMO, I believe the 'this nurse' is more objective. That I wrote 'the notes' may not necessarily mean I did the procedure. I have worked in the ER where everyone is helping each other, however, it is the duty of the primary nurse to make sure her pts chart is accurate. Either, by making sure the 'helpers' chart their stuff or charting it 'for them'. For example, if someone helps me insert a foley on a pt I'll write '2300hrs; foley inserted by Xyz, RN'. Or 'urine sample collected by Abc, ER Tech and sent to lab as ordered'. In that way, you let the reader know who and who did what, even though you're the primary nurse. I have seen and work a couple of lazy nurses who chart everything as if they performed the procedure. I don't think that's right, too. Though, it makes them look like they work hard, yet, if anything comes out of it, guess what, she'll have to answer for ALL of them too... lol...

The main thing is to remain focused on the pt and describe care as objective as possible.

.... just my 2cents.....

SubSippi · Jul 2, 2015

I googled why journalists are taught to write in third person. I found two reasons that could apply to nursing documentation...

First, as other posters have stated, the third person allows the writer to give an objective account of what happened. Using "I" or "me" in a sentence automatically removes the objectivity. Nurses are taught to document objectively, but we are not trained writers, and there is no standard language format we are taught to use. The documentation in question may not be the most eloquent, but the fact that we don't have editors that proof-read or creative writing degrees, and are expected to document in real time should be taken into consideration.

Second, writing in the third person allows someone to give a real time account of an event. If something is documented at 11:30 in third person, you can safely assume that was the exact time it happened. If it was documented in first person, exact time cannot be assumed, since past tense must be used, making the sequence of events more open to interpretation. Which, to me, seems like a valid reason not to document in first person.

I'd cite the websites, but since I did a quick search, I really only saw opinion, blog-type pages. Maybe an English textbook with these rules could be an "expert witness."

MunoRN, RN · Jul 2, 2015

I'm not sure you can really call something either first or third person without any speaker pronoun usage since that's what defines perspective.

Notes typically are written without pronouns which signifies an "impersonal" perspective which is categorized as a type of third person; "This was done, that was done". Stating "I did such and such" would be first person. Stating "The nurse" or "A nurse did such as such" when the writer is referring to something they did would be third person.

As a poster pointed out, "This nurse" or "this writer" is also first person since it is meant to be a pronoun, replacing "I", just a less clear way of saying "I". So if you're still saying "I", except with a phrase meant to translate to "I", then I'm not really clear how that alters the objectivity of the statement. It does however take the impersonal third person and turns it into first person.

I've always been under the impression that it's the characteristic of the finding itself that makes it objective or subjective. "Patient is cool to touch" is subjective. "Temp = 35.0" is objective. While it's superfluous to add "I found the patient's temp to be 35.0" it's still an objective statement.

ThePrincessBride, MSN, RN, NP · Jul 2, 2015

I was never taught to chart like that. I either use neutral or "I". I never see a doctor refer to himself or herself as "this doctor. "

First person is crystal clear.

kbrn2002, ADN, RN · Jul 2, 2015

Interesting topic, thanks! We, as in all the nurses in our system , use narrative charting. LTC/SNF might be the only area of nursing that still uses narrative charting. Maybe it's a regional thing but all of our nurses tend to chart in neutral format. When 1rst or 3rd person is necessary for clarification on who did what the charting I've seen [and do myself] is "writer contacted MD" or "Nurse xyx contacted MD"

Way back in the dark ages when I learned nursing charting the rationale given is keeping personal pronouns and names out of the charting helps to maintain objective charting. The moment I chart "I saw or did whatever" it adds a subjective component.