Notes in 3rd person style

[MunoRN]

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.

[Spidey's mom, ADN, BSN, RN]

I think the terminology people are looking for is "passive voice" vs "active voice".

Example:

"Wound was debrided and dressing was changed" (passive voice)

Yes, but by whom?

"This RN (or 'I') debrided the wound and changed the dressing" (active voice)

Sorry if that has already been mentioned

The passive voice, I was taught, leaves too much information out.

The only place I chart on paper anymore is when a hospice patient is in LTC because they don't have EMR there yet. And so if I'm writing about wound care, I have to be specific about who did it since the nurses in LTC are there 24/7 and I'm there 30 minutes maybe twice a week.

I know someone has already posted this but the link shows exactly what I was taught in nursing school and I graduated 18 years ago.

Do not use the first person.

In narrative charting, avoid the use of I” and me.” Instead of I observed . . .” use This nurse observed . . .” I change the dressing daily,” becomes Nursing changes the dressing daily.” This helps to maintain the impersonal tone discussed above.

Lots of other links at the bottom of article about "Writing As A Professional Nurse".

https://owl.english.purdue.edu/owl/owlprint/922/

[NursesRmofun, ASN, RN]

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

"Patient threw IV pole at this writer. "

[NursesRmofun, ASN, RN]

The problem is that this is one likely scenario for how that questioning will go:

Lawyer: "Do you follow established standards of nursing care?"

Nurse: "Yes"

Lawyer: "Is this because you believe following established standards will help ensure the best care possible?"

Nurse: "Yes"

Lawyer: "In your note you mentioned that a "writer" spoke with residents daughter who is concerned re abc..., was this writer a licensed caregiver or a scribe?"

Nurse: "I was referring to myself"

Lawyer: "Isn't the established standards in the English language to write "I spoke with the residents daughter...."

Nurse: "I guess, but that's not how I refer to myself in my notes"

Lawyer: "You don't think that could be confusing to someone reading your note?"

Nurse: "maybe"

Lawyer: "So even though the purpose using standardized English is to ensure accurate communication between caregivers, you chose to communicate in a non-standard format? If you don't believe in ensuring accurate communication by using standardized methods, how are we to believe that you also adhere to standards of care?

I would answer that the established standard in nursing documentation is not necessarily the same as the standard English language. The lawyer for the facility during the deposition would say, "Mark it for a ruling", most likely.

[canigraduate]

Referring to the post and quote above:

The simple answer is for the nurse not to say anything that stupid, I think.

My reply would have been, "Charting language, much like legal language, is specialized to the industry and its conventions are different than those of standard English. My charting adheres to those conventions."

And, instead of "maybe", "Charting language, like legal language, can be difficult for persons outside of the industry to understand but is perfectly clear to other practitioners."

What do you think?

[MunoRN, RN]

I would answer that the established standard in nursing documentation is not necessarily the same as the standard English language. The lawyer for the facility during the deposition would say, "Mark it for a ruling", most likely.

If it was an actual standard of care then it could presented as such, but it's not. The legal definition of "standard of care" is pretty strict, there has to be near universal agreement that it's something should always be done, failure to follow a true standard of care is extremely rare and constitutes negligence. It really doesn't appear that there is anywhere close to that level of agreement on the use of "this nurse" or "the nurse". Since it's not a standard of care, the actual rationale is usually what's going to explain it best to a jury.

[canigraduate]

If it was an actual standard of care then it could presented as such, but it's not. The legal definition of "standard of care" is pretty strict, there has to be near universal agreement that it's something should always be done, failure to follow a true standard of care is extremely rare and constitutes negligence. It really doesn't appear that there is anywhere close to that level of agreement on the use of "this nurse" or "the nurse". Since it's not a standard of care, the actual rationale is usually what's going to explain it best to a jury.

Instead of standard, how about convention? Does that have a legal definition, too?

[NursesRmofun, ASN, RN]

If it was an actual standard of care then it could presented as such, but it's not. The legal definition of "standard of care" is pretty strict, there has to be near universal agreement that it's something should always be done, failure to follow a true standard of care is extremely rare and constitutes negligence. It really doesn't appear that there is anywhere close to that level of agreement on the use of "this nurse" or "the nurse". Since it's not a standard of care, the actual rationale is usually what's going to explain it best to a jury.

That is interesting. I thought the way we chart would be a standard since I am pretty sure that is what I learned in my nursing programs. I guess they should come up with a standard of care for documentation.

[NursesRmofun, ASN, RN]

By the way, I was a witness in a trial and the lawyer never asked anything about the way anything was documented as far as wording. He only wanted to point out a certain medication in the notes. But I guess that angle might be pulled out if the identity of the individuals giving care were missing, I am guessing.

[MunoRN, RN]

Referring to the post and quote above:

The simple answer is for the nurse not to say anything that stupid, I think.

My reply would have been, "Charting language, much like legal language, is specialized to the industry and its conventions are different than those of standard English. My charting adheres to those conventions."

And, instead of "maybe", "Charting language, like legal language, can be difficult for persons outside of the industry to understand but is perfectly clear to other practitioners."

What do you think?

The problem would be the highlighted part. It doesn't appear like it would be particularly difficult to find other practitioners who find "this nurse" or "the nurse" to be less than perfectly clear.

[MunoRN, RN]

Instead of standard, how about convention? Does that have a legal definition, too?

Not that I know of, but basically what you'd be saying is that it is something that is done by many nurses but not to the level of a standard of care, which then would need a good rationale. Just arguing that many nurses do something a certain way often won't get you very far, because it's not difficult to find past examples of things "many nurses do" that turned out to be a bad idea.

[MunoRN, RN]

That is interesting. I thought the way we chart would be a standard since I am pretty sure that is what I learned in my nursing programs. I guess they should come up with a standard of care for documentation.

Using "passive voice" or whatever we want to call it does appear to be pretty standard, using terms such as "this nurse", "the nurse", etc do not appear to overwhelmingly common.

[canigraduate]

Hmmm, I thought the standard of care was doing what another reasonably prudent nurse would do?

Many other reasonably prudent nurses chart that way.

I'm really trying to find something for you, and this is kinda fun.