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What's up with this RN?

Nurses   (2,115 Views 30 Comments)
by hherrn hherrn (Member)

114 Likes; 16,508 Visitors; 1,489 Posts

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hawaiicarl has 28 years experience as a BSN, RN and works as a Charge Nurse.

41 Likes; 6,683 Visitors; 285 Posts

That's right up there with "pt appears to be sleeping or resting quietly", I got that patient on a monitor, and judging from their sleep apnea they ARE sleeping.  Well until they wake up choking on their tongue again.

 

Cheers

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273 Likes; 7,882 Visitors; 727 Posts

Several of my notes were used in court for a patient.

In this particular case (combo med/psych), I used “this writer was notified of  ...” in the beginning of one of my notes RE: a particular violent night (multiple restraints, multiple de-escalation techniques, etc that failed, a staff injury, etc). 

I was taught this way, and at 0300, 4 hours past my scheduled departure time I was trying to be thorough and detailed but I was exhausted.

The hospital lawyer seemed fine with it?

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Seeing Myself Out has 6 years experience.

29 Likes; 1,099 Visitors; 52 Posts

I have seen different versions of how nurses refer to themselves when they chart, over the years I chose to use "writer" just because it suits my writing style the best. 

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Daisy4RN has 20 years experience.

498 Likes; 1 Follower; 5,608 Visitors; 761 Posts

I was taught to not write any of those, this RN, RN, writer etc, it was assumed it was this RN because of the signature at the end of the note. Over the years it became policy to write RN (RN came into room, found pt in bed blah blah), then as someone else stated it became "this RN" to further ID/clarify which RN it was. I mostly see people using "this RN" now. Either way doesn't bother me as long as we all CYA!

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11 Likes; 54 Visitors; 5 Posts

I've honestly ever thought about this before. I was taught the 'this RN' or 'RN' in school and it just stuck. The electronic charting we use is mostly clicking boxes...unless it's a notification of some sort and then you only get like 2 1/2 lines to write something out. So it's a lot of "RN notified of pt c/o blah blah blah..." If I talk about another RN (witness or something) in a note, I will write "Jane Doe RN" for clarification. Even MD notes are short and to the point "Nurse at bedside. Nurse this. Patient that. Dispo this." It's all short and to the point.

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Kallie3006 has 6 years experience as a ADN and works as a Jack of all trades, master of none.

95 Likes; 4,898 Visitors; 321 Posts

I was also taught to use "this RN" or "this writer" in school but have not used that in practice.  My thoughts are if I am writing the note then unless stated it is me that informed the doc, changed the dressing, yada yada and the stating of "this RN" does not bring any more clarity to the entry in question.  

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