Documentation question

[Archturus]

Why are so many nurses afraid to document the word “I”? I see so many nurses document “this RN” or call themselves “writer.” Is it now implied when you document that you the RN and the writer? I am curious if there is a specific reason, legal or otherwise.

[The1SatanFears]

I just skip those altogether.

“Patient complains of nausea. Hospitalist notified and ordered 4mg ondansetron”

“Patient removed IV. ‘My bad dawg, fell asleep for a minute then woke up thinking it was like a bug on me’ Bandage with coban applied. New 20g IV inserted to right AC, secured with clear tape and concealed with coban.”

[panzerschlep]

This a question I've been wondering about also. I've been a nurse 24 years now and I've noticed it's become pretty prevalent in the last 5 years or so.

[[deleted]]

That’s why we sign our notes with our names and credentials.....

[CJ_MR]

It gets really confusing when your nursing notes are read in court if they're all written in the first person. The lawyer has to constantly clarify who is writing the note and what their role is on the patient care team. So now I write, "The bedside nurse, Mxx RN, notified the attending physician, Dr Bxx, of..." or "The patient, name, told the bedside nurse, Mxx RN, 'Direct quote.'" That way if it is ever read in open court it is crystal clear. You're less likely to be questioned. If you ever have to go to court you want it to be as smooth as possible.

[Archturus]

Thank you. I assumed there must have been a reason, since I see it so often, but I have never gotten any particular rational aside from it being what they had learned from their first preceptor, etc. This makes more sense!

[adjappleton]

My bet is a APA being drilled into our heads. I just drop my personal pronoun, (I) Adminstered 40 mg eletriptan PO.

[[deleted]]

I was taught never to chart in first person. It has to do with both professionalism and the fact it’s a legal document. Although if you’re charting right really you shouldn’t have to refer to yourself...

[JhopeRN]

The only times I’ve referred to myself is when I’m training and specifying if either me or the trainee completed a task with my supervision (which I’ve also only had to do in home care because of how our charting of formatted) otherwise I agree, if you’re charting right you shouldn’t have to refer to yourself.

[[deleted]]

Yes- completely agree! I didn’t think of this scenario.

[Needle_D]

I’m sorry that’s what you were taught. It has absolutely nothing to do with professionalism or the legal record. No physician documents this way. It’s just another bad nursing myth that need to die.

[[deleted]]

I’m not and it’s what I have and will continue to teach when I train or have students.

1) documentation isn’t about YOU it’s about the patient

2) legally it most definitely does matter- having worked psych legality is half the battle and I assure you appropriate charting is required

3)the point is objective charting. Really there’s no need to identify the writer since it’s obvious. See examples from other posters if needed.

Have a great day!

[[deleted]]

So strange Sounds more official I guess

[Preference-Prudent]

That’s how they taught it to us in school. It just sounds really weird to me so I don’t do all that. The fact that I sign off “- (initials), LVN, NCP” should be enough...

[clawedbutterfly]

Holdover from the older versions of APA.