Why do nurses chart in 3rd person?

[Cobweb]

I've always found charting pretty artificial, anyway, but I've always wondered why we chart in 3rd person? Why don't we say "I found" or "I did..."? Anybody know?

[xtxrn, ASN, RN]

I've worked at places that did allow for "normal" wording... but-

a) it's about the patient, not the nurse

b) it's supposed to be objective

Writing in the first person can sound subjective and about the nurse's experience- not what the patient is experiencing...imho :)

[relgis15]

Mainly because we observe the patient from a third person perspective.

Luckily for you, I minored in english so I will give some insight.

First person is generally reserved for informal writing. When writing in a professional context, third person is preferred because it removes (you) from the picture and places emphasis on the subject. The sentence is written better when emphasis is placed on the subject, rather than shared between the subject and the pronoun.

[EmergencyNrse]

All your charting is for the Lawyers.

It's proven, no one reads the chart but them...

[mindlor]

Take writing 101 in college, writing in the first person is generally discouraged.....

[emtb2rn, BSN, RN, EMT-B]

Same reason you use "consistent with" instead of "looked like". This rn does laugh sometimes when reviewing this rn's charting.

[bratmobile]

I agree with all the above plus, many different people are adding to and working with charts so best to keep in 3rd person so it is only about the pt..l remember being taught not to chart the phrase "Patient easily aroused" lol

[AnonRNC]

I avoid the pronoun. "Mom teary, social services consult offered." But when it gets complicated, like a big social concern or inappropriate comments, I keep it simple: "Patient said... I replied...."

[jnndub]

Mainly because we observe the patient from a third person perspective.

Luckily for you, I minored in english so I will give some insight.

First person is generally reserved for informal writing. When writing in a professional context, third person is preferred because it removes (you) from the picture and places emphasis on the subject. The sentence is written better when emphasis is placed on the subject, rather than shared between the subject and the pronoun.

I never questioned why we chart in third person, but thanks for the English lesson (no sarcasm at all)! I never did all that well in English and appreciate rules and knowledge I probably should already know by now!

[bookwormom]

I have used first personat times and I think it is appropriate, especially for clarity. If you say:"Called physician..." it is not crystal clear that you personally did so; the unit clerk could have done it. If the patient punched you, why not say, "Patient punched me..." To say "Patient punched the nurse..." is confusing. I have seen people chart "Patient punched the undersigned..." and I think that is really unnecessarily wordy. I do avoid the pronoun I, however, when charting routine info.

[PsychNurseWannaBe, BSN, RN]

I refer to myself as "writer" when I chart... not the "nurse". If that helps.

[LouisVRN, RN]

I don't refer to myself at all in my charting. I only chart what the patient was doing what happened to the patient etc. Ex. Pt pacing in room yelling and swearing. Encouraged pt to calmly verbalize concerns. Pt verbalized concerns regarding having not yet seen dr. X.