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]

Example based on patient who has already had shift assessment for LOC/neuro, ortho, ambulation/gait, etc.

12/12/2011 2145

"Pt. vomited 300 cc partially digested food @ 2130. No medications noted in vomitus. BP 110/74, p-96, r-20, temp- 99.4 tymp. No c/o pain or severe, continuing nausea. Skin warm, slightly diaphoretic, and has some circumoral pallor- otherwise pink with cap refill

Refused po Zofran. MD notified of above, and order received for Zofran 16mg IVP q4h prn.

Order sent to pharmacy- and awaiting processing. Cool cloth provided for behind patient's neck as requested. Pt. states nausea is better, but still present- and would like Zofran when it arrives from pharmacy."

12/12/2011 2200

"Zofran arrived from pharmacy and given to pt per orders".

OK. You are already the assigned nurse. You did the shift assessment (signed your name- so it's clear that it's YOU). This (once again) is about the patient. The individual nurse is so totally irrelevant (unless you get sued over writing novels in the chart that in some way indicate negligence). You sign your name after every entry. Unless you chart that someone else did something, who else would it be?

Even if the patient beats you to a pulp, it's not about you.... "Pt. became violent and repeatedly struck this nurse about the head and neck and poked an eye out. Pt. restrained by security and given PRN IM antipsychotic by Nurse Dingbat @ 2345"

[nurseprnRN, BSN, RN]

"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."

why do nurses chart in the third person? i have no idea. i think it's an historical artifact, because historically nurses were nuns and others whose lives were supposed to be invisible and selfless, handmaidens, mere conduits for the care that really came from god. or a physician. really.

there is absolutely nothing wrong with saying, "at 0830, i found that the patient had bilateral crackles in the lower bases, 3+ pretibial edema, jvd to the angle of the jaw at 45 degrees, and ...." then someone else knows it's my assessment, not something i saw someone else do (and maybe misunderstood).

i loathe the passive voice and as an editor i try really hard to get rid of it. the challenge is to try to use a third-person perspective without leaving doubt as to who the actor is in the sentence. "mistakes were made (by whom?)" is just classic weasel language a miscreant uses to dodge responsibility. also, consider the differences between, "algernon loves clarissa" and "clarissa is loved by algernon."

"patient was placed in the left lateral decubitus position (by whom?)" is it that much harder to say, "dr. smith did the procedure with the patient in the left lateral decubitus position"?

it is my experience that many people use complicated language because they think it looks more "educated," when in reality it just clogs things up. i told my students that i thought it likely that their patients walked and talked, not ambulated and verbalized. if short words were good enough for winston churchill, the best native english speaker in history imnsho,they're good enough for me.

[SDALPN]

I took a legal charting class by a nurse/lawyer. She said writing "I" instead of "this nurse/writer" was fine to use. I don't use it often since I try to word my notes without using "I". But occasionally I will use it when necessary. I think it sounds silly to write anything else. I understand the English side of it. But if the sentence relates to the patient and isn't an opinion I will write "I".

[SDALPN]

don't ever write "i found...". when i took that legal class there was a case we studied where a nurse lost the case for writing the word "found". the lawyers said that by writing the word "found" that she must have lost the patient at some point.

"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."

why do nurses chart in the third person? i have no idea. i think it's an historical artifact, because historically nurses were nuns and others whose lives were supposed to be invisible and selfless, handmaidens, mere conduits for the care that really came from god. or a physician. really.

there is absolutely nothing wrong with saying, "at 0830, i found that the patient had bilateral crackles in the lower bases, 3+ pretibial edema, jvd to the angle of the jaw at 45 degrees, and ...." then someone else knows it's my assessment, not something i saw someone else do (and maybe misunderstood).

i loathe the passive voice and as an editor i try really hard to get rid of it. the challenge is to try to use a third-person perspective without leaving doubt as to who the actor is in the sentence. "mistakes were made (by whom?)" is just classic weasel language a miscreant uses to dodge responsibility. also, consider the differences between, "algernon loves clarissa" and "clarissa is loved by algernon."

"patient was placed in the left lateral decubitus position (by whom?)" is it that much harder to say, "dr. smith did the procedure with the patient in the left lateral decubitus position"?

it is my experience that many people use complicated language because they think it looks more "educated," when in reality it just clogs things up. i told my students that i thought it likely that their patients walked and talked, not ambulated and verbalized. if short words were good enough for winston churchill, the best native english speaker in history imnsho,they're good enough for me.

[wooh, BSN, RN]

Don't ever write "I found...". When I took that legal class there was a case we studied where a nurse lost the case for writing the word "found". The lawyers said that by writing the word "found" that she must have lost the patient at some point.

Meh, I can rip apart anyone's charting no matter what they do or don't use. I've got nothing on an experienced attorney.

Write what happened. Objectively. If someone wants to tear it apart, there's not much you can do to stop them.

[relgis15]

"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."

why do nurses chart in the third person? i have no idea. i think it's an historical artifact, because historically nurses were nuns and others whose lives were supposed to be invisible and selfless, handmaidens, mere conduits for the care that really came from god. or a physician. really.

there is absolutely nothing wrong with saying, "at 0830, i found that the patient had bilateral crackles in the lower bases, 3+ pretibial edema, jvd to the angle of the jaw at 45 degrees, and ...." then someone else knows it's my assessment, not something i saw someone else do (and maybe misunderstood).

i loathe the passive voice and as an editor i try really hard to get rid of it. the challenge is to try to use a third-person perspective without leaving doubt as to who the actor is in the sentence. "mistakes were made (by whom?)" is just classic weasel language a miscreant uses to dodge responsibility. also, consider the differences between, "algernon loves clarissa" and "clarissa is loved by algernon."

"patient was placed in the left lateral decubitus position (by whom?)" is it that much harder to say, "dr. smith did the procedure with the patient in the left lateral decubitus position"?

it is my experience that many people use complicated language because they think it looks more "educated," when in reality it just clogs things up. i told my students that i thought it likely that their patients walked and talked, not ambulated and verbalized. if short words were good enough for winston churchill, the best native english speaker in history imnsho,they're good enough for me.

this is absolutely horrible advice. i have worked in a number of technical arenas from information technology to nursing to engineering etc. it is never okay to write in 1st person! not only does it make the writer sound like an idiot, but it exposes the author to legal issues.

i have never ever seen a chart written in 1st person, and the fact that you called me out on my comment really gets under my skin because it's obvious that you don't have the slightest clue of what you are talking about.

"i think it's because nurses were nuns"

what a load of crap.

[PsychNurseWannaBe, BSN, RN]

I guess people chart differently. I stay away from "found" I was taught to. Instead the word I used is "noted".

[CompleteUnknown]

I tend not to use 'I' but if I need to, I do. I don't see how it's unprofessional or necessarily subjective. Personally, I think 'writer' or 'this nurse' sounds really odd, almost like a desperate attempt to avoid saying 'I' or 'me', but a lot of people have been taught to do it that way.

I can't say found because that implies the patient had been lost? Come on....

We're not writing a thesis or a technical manual or a contract, and we don't have editors standing by to check our work. Wooh is right, anyone's charting can be pulled apart and torn to shreds. Hopefully there will never come a day when the nurse's note has to be approved by legal before it appears in the chart.

[xtxrn, ASN, RN]

I guess people chart differently. I stay away from "found" I was taught to. Instead the word I used is "noted".

Same here. Also, "found" can imply that someone else didn't "find" it- so why didn't they?

Noted is less personal...

[BluegrassRN]

Our docs chart their H&Ps in first person. I chart in first person; I never use "this nurse" or "author". It's silly. I've never seen a doc do that on any of their charting. If that works for them, it will work for me, too.

And yes, I do have a language degree. I understand the nuances of professional writing. I also understand that the silliness that requires such third person terms can lead to confusion. Best to be clear and succinct.

[bookwormom]

As we move more into electronic medical records, I believe we'll be doing less and less narrative charting--mostly just clicking on boxes. The assumption will be of course, that "I" am the only one who has the password and who can make the entry. I do believe there will always be the need for some narrative notes, however, and I think we should use language which promotes clarity.

[MinnieMomRN]

Charting is the documentation of clinical findings. Therefore, the scientific style of third person construction is used.