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.

[MunoRN, RN]

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.

The are reasonable and prudent nurses that do use those terms, but it's also not hard to find examples of reasonable and prudent nurses who don't, which means it's not a standard of care.

[canigraduate]

Bummer, that was my last idea.

[Spidey's mom, ADN, BSN, 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.

I think it is standard of care documentation - using "this nurse" instead of "I". So far in my searching regarding professional nurse charting rules, this is the standard answer. It was what this nurse was taught in medical terminology and the nursing program. I was taught that it is standard.

Obviously not all nursing schools are alike.

[caliotter3]

My nursing program did not teach charting, like it did not teach how to administer meds. I distinctly remember learning how to chart in the third person on my first job. Same place where I learned how to do a med pass.

[blackribbon]

I am a new nurse who is older. I don't know that anyone taught me how to write a nurse's note but what came naturally is 3rd person because I have been taught this is how professional writing is done. For the IV pole question, it would simple be "Pt threw IV pole at RN". If a RN other than myself is referenced, then I include the RN's name "Kelly K. witnessed the situation and assisted RN with restraining the patient." Yes, it is weird but to say "I did this" feels like the focus is on me and not the situation...and doesn't feel like an objective way of writing." I also float the psych floor where we are encouraged to use "I saw this" or "I did this" but it seems unnecessary...either "Pt did this" or "Kelly K. reported witnessing patient doing X" conveys the same information and keeps it more objective.

[SarahMaria, MSN, RN]

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?

I have a law degree in addition to my RN, and I am not aware of any legally necessary reason for nurses to write in the third person. It seems confusing and unnatural.

[emmy27]

I suspect it arose as a convention (and in studying and working across multiple southeastern states, it has seemed to me to be a widespread one- all the notes I read are either entirely passive or contain the occasional "this nurse" or "this RN" to clarify where needed- I don't think I've ever encountered a true first-person nursing note in the wild) as a product of the intersection between the conventions of academic writing (where you don't say "I" or "me") and the actual demands of charting care, which sometimes require an ability to specify who did something beyond the capacity of the passive voice.

"This RN" might sound weird, but the only alternatives are using a first-person pronoun (which most of us have had beaten out of us in the course of years of academic writing) or referring to yourself by name in the third person, both of which are very jarring, as well.

[Xantee]

What is going on with nursing education? I graduated in 94, was never trained to use the term "this nurse" or "this writer". When I refer to myself in nursing documentation, I will simply use I/me/myself as needed. I believe that is the clearest documentation of all, especially when there is an electronic signature that verifies who I am. I've had to deal with legal teams in depositions.... clear documentation is really necessary, you don't want to have to explain why you phrase it a certain way or it looks like you don't know what you are doing.

[meanmaryjean, DNP, RN]

A nurse is getting deposed for a court case, it doesn't sound like there is anything deficient in the care she provided, so the opposing lawyer is trying to create an argument that her charting is unreliable or at least is potentially confusing due to an awkward use of english and use that to question her overall competency. If we can provide some sort of benefit 3rd person charting provides that outweighs the potential confusion then we're fine, but we're not sure what that benefit is.

I know this is an old thread- but I suspect this charting reflects the unholy emphasis many nursing programs put on APA formatting to the exclusion of (it seems) content.

[~Mi Vida Loca~RN, ASN, RN]

I am glad this topic got bumped, interesting read. I have worked at hospitals in CO, WY, MD and NC and had never seen "this nurse" used until I moved to NC. I always wondered why nurses typed that way.

[joe007]

I think people should document in first person and use other coworker's names and positions. The idea of this third person lingo being a standard and not using names being superior is a bunch of bunk and putting you as the note writer at risk. Ultimately, if you refer to "charge nurse" instead of "Billy the charge nurse" lawyers will ask you who the charge nurse was that day and you'll have no idea. Schedules may have been lost, manipulated, etc. and you will have to rely on your unit/hospital to provide that information, which may or may not be accurate. What if they ask you how many nurses were working that day and out of those nurses how many are qualified charge nurses? If so, how do you know which charge nurse you told which information, AKA they could posit you told the wrong charge nurse? Anyhow, if you refer to "MD" which "MD" are you referring to? How many physicians work in your hospital on day shift? How many hospitalists cover your unit/hospital? How do you know it wasn't a specialist you talked with? etc.? It seems that the style works in favor of the hospital and coworkers at your expense. Shocking, I know, to think that the nursing industry is set up to be the patsy for billion dollar corporations and multimillionaire physicians.

[FolksBtrippin, BSN, RN]

On 7/1/2015 at 6:18 PM, MunoRN said:

"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.

My understanding of the use of "this nurse" "this writer" etc, is that it stems from APA format, in which it is unacceptable to use first person.