Question about tense used in documentation?

fab4fan · Jun 17, 2004

I always use "writer," too, but I have no idea why.

kidluvinRN · Jun 18, 2004

I usually say "this RN" if I need to refer to myself in charting.

suzanne4, RN · Jun 18, 2004

Hello all and thanks in advance for any light that you can shed on this for me!
I work in a retirement home, but am a BSN student (starting 4th year in Sept...YAY). Since we are retirement and not nursing, our guidelines are a bit more relaxed than in a traditional LTC (hence why I am permitted to work as a "nurse" and not psw/hca). One peculiarity in particular that I've noticed is that when charting on residents...the other staff in my facility never use the word "I". When referring to themselves, they say "writer".
Example: "When the resident was approached by writer he became very weepy."
I don't get it. If I'm signing my name at the end, shouldn't it be obvious that I am the writer!?
Does anyone know of any general guidelines to follow while charting with regards to use of person, etc that I may not have picked up yet? (BTW: I've done mostly charting by exception, and computer-based clinicals, so I lack some experience in paper charting).
Thank you muchly! :balloons:
Lys

First, you should not be working as the "nurse" as you do not have a license to practice as one. If you are using the title "nurse" you could get inot trouble with the BON in your state. Just because the administrators may call you that, you aren't. Is there a registered nurse there working with you?

When it comes to charting, why do you ever need to use the word "I" or the writer? I have never used either in a client's chart in my whole career.

The example you have above sounds like it is something in a novel, doesn't belond in a medical record.

You could state: Client appears weepy when approached by staff. Then state is this happens all of the time, or first time that you noticed. And then what happened. What did you do? If there is something out of the ordinary, you need to state what was done to rectify it. Or is this normal for the client? This is what you always need to include in your charting.

Hope that this helps.....................and good luck :balloons:

leslie :-D · Jun 18, 2004

i use 'writer' but like fab4, have no idea why.

IamRN · Jun 18, 2004

Never gave it much thought :) ...that I never rever to myself. I just note "pt stated he had cp, asked him to rate and he rated at 9." "Pt assisted back to bed (x2 staff for assist)..." etc.

IamRN · Jun 18, 2004

First, you should not be working as the "nurse" as you do not have a license to practice as one. If you are using the title "nurse" you could get inot trouble with the BON in your state. Just because the administrators may call you that, you aren't. Is there a registered nurse there working with you?

I meant to comment on this too. OP could you clarify?

Dixielee, BSN, RN · Jun 18, 2004

I have been a nurse 30 years and I can't tell you why I chart the way I do either, but I rarely refer to myself. In the rare occasion I do, I also say "this RN". Usually I do it in situations that may potentially be a legal case, such as a rape exam, child abuse etc. Then I might say...pelvic exam per Dr. Jones with this RN in attendence. Or patient stated to this RN such and such happened. In most circumstances though, I would just say patient states chest pain rated such and such, or patient requests pain medication, or even family reports such and such, or just objective data such as patient presents sitting up in bed, awake, alert, oriented, or drowsy but arousable. I agree that it does sound more professional, objective and concise to chart as succinctly as possible and try not to get too chatty.

BittyBabyGrower, MSN, RN · Jun 18, 2004

I usually write, patient stated to this RN. I wouldn't say staff, because, if it needed to go to court, then they need to identify what was said to who.

Most of the time I don't refer to myself.

Nurse Ratched, RN · Jun 18, 2004

LIke others, I don't generally refer to myself, but when I do, I use "this nurse" e.g. pt became agitated and struck this nurse (bad example, but it's psych and the first one that came to mind lol.)

Lys · Jun 18, 2004

Thanks for your replies everyone,

Just to clarify for those of you whom were inquiring, I work in a Retirement Residence, not a LTC facility located in Ontario Canada. We are regulated by ORCA (ontario residential care association). We provide assistance with ADL's and medication assistance for our residents who are all mobile (have to be independent and cognitively capable).

My rightful title is "Charge staff" and the reason that I put the title "nurse" in quotations is because I realize that I am not registered yet, and do not have the right to be called as such, but when a resident calls out "nurse" I am the one who is to answer.

Thanks again!! :-)

Gompers, BSN, RN · Jun 19, 2004

You know I never thought about it...

I actually think that I omit it all together. I just find a way to word things so that I don't have to include "I" or "me" or "this RN" - kinda like in Spanish. I'll chart, "inserted new NG tube" rather than "I inserted new NG" or "NG inserted by this RN." If you're the one charting it, you're the one who did it, so why do you even have to identify yourself? If it wasn't you, you'd be charting, "Dr. Smith inserted new NG," or something similar anyways, right?

Using the original poster's example, I'd change: "when the resident was approached by writer he became very weepy," to: "resident became very weepy when approached," etc.