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?

[nurseprnRN, BSN, RN]

"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."

"legal issues" do not go away merely because it's a little harder to determine who did what because someone thought it was appropriate to obfuscate the situation by not using names. it is my experience that people who cite "legal issues" haven't been involved with them.

i have seen a great many charts using the first person. i will grant you the "nuns" thing was a bit over the top, but it fits the historical record in fact and philosophy for early nursing, and stand by my opinion.

as to who is full of crap, we will agree to disagree, then, preferably without being disagreeable.

[SuesquatchRN, BSN, RN]

"legal issues" do not go away merely because it's a little harder to determine who did what because someone thought it was appropriate to obfuscate the situation by not using names.

i don't use anmes. let 'em dig.

[MunoRN, RN]

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.

Writing in 3rd person does nothing to protect you from legal issues. Accurate and complete charting, without superfluous information, is what protects you from legal issues. Our legal Nurse consultant likes to share a specific example; A nurse charted "this Nurse" notified the MD of a critical finding. The opposing lawyer argued that the Nurse in question should have charted who specifically notified the MD, rather than "this Nurse". You have to remember that in a court of law the audience is often a jury, and when they hear "this nurse" they hear it as the common usage of this terminology, such as "this guy walks into a bar". Our job is to be accurate, not appease technical writing gestapo.

[nurseprnRN, BSN, RN]

"i don't use anmes. let 'em dig."

have no fear, they will. i have been known to go to the nursing department to check schedules to see who was working to do so.

[SuesquatchRN, BSN, RN]

"i don't use anmes. let 'em dig."

have no fear, they will. i have been known to go to the nursing department to check schedules to see who was working to do so.

oh, i have no doubt that they will. but i'm not going to hand it to them.

[leslie :-D]

the problem being, there aren't any hard and fast rules about writing nurse's notes.

believe me, i've looked.

i've used "i", "writer", and "this nurse"...

usually going with writer, but will use "i" when absolutely necessary.

i also use names of persons i've spoken with.

there really isn't any right or wrong way to document - it is all subjective preference.

leslie

[PsychNurseWannaBe, BSN, RN]

Writing in 3rd person does nothing to protect you from legal issues. Accurate and complete charting, without superfluous information, is what protects you from legal issues. Our legal Nurse consultant likes to share a specific example; A nurse charted "this Nurse" notified the MD of a critical finding. The opposing lawyer argued that the Nurse in question should have charted who specifically notified the MD, rather than "this Nurse". You have to remember that in a court of law the audience is often a jury, and when they hear "this nurse" they hear it as the common usage of this terminology, such as "this guy walks into a bar". Our job is to be accurate, not appease technical writing gestapo.

My only comment is our charting is signed either electronically or with a signature and credentials. That will tell you who, "this nurse" or who "writer" is.

The main thing is to chart smart and defensively. And like OPs have said... you can tear apart anyone's charting. And I totally again with Sue... let 'em dig. I am not going to make their jobs easier! I will not chart another person's name in charting. When I was a staff nurse, it would be Peer RN or Peer staff nurse. As a manager, I will chart LPN Staff Nurse or RN Staff Nurse... They can go digging in the schedules and stuff. To heck with lawyers!!

[MunoRN, RN]

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.

We actually use 1st person perspective quite often in our charting, and you can see many examples of that in this thread. The most obvious is the use of "this Nurse", which indicates a first person perspective, being nothing more than a synonym for "I". If "the Nurse" or "a nurse" were used, then that would be third person. Other times we just omit the pronoun altogether, such as "encouraged patient to use I.S.", which is the same as "I encouraged patient to use I.S." in terms of perspective just without a pronoun, essentially making nothing more than bad grammar. If that was written as "patient was encouraged to use I.S.", then that would be third person.

[nightengalegoddess]

This is when it is kind of interesting to identify how self-centered we all may be when we have a hard time writting or saying anything without "I" contained in it. "THIS RN" finds it relaxing to chart as if "This RN" did not exist, but as if her brain and senses were the only thing writting; as if I were not even there but some almighty assessor were writting my notes. I actually love charting. But I always got A's in English back then. Now, Math.......give me the calculator. Thinking about this now....charting is kind of Buddhist and Zen.....no ego ought to be involved at all.

[nightengalegoddess]

Re: MunoRN's statement; really don't know how a lawyer could possibly down an RN for writting "this nurse" if her signature were at the bottom of the note.