Writing as a Professional Nurse
The field of nursing requires a great deal of swift, accurate writing. You will need to fill out reports and charts correctly and completely and record your interactions with doctors and patients fairly. In addition, you must always be prepared to defend the information you record. The material below is intended to help you get used to this type of writing both in school and in the field of nursing.
Three General Rules
This may seem to go without saying, but you should remember that accuracy is important even beyond the obvious areas like medication administration and treatment procedure. Accurately reporting sequences of events, doctor’s orders, and patient concerns will protect you from scrutiny.
Example: “Did dressing change.”
If this is the entire record of you performing a dressing change for a patient, then exactly what you did is up to interpretation. A more precise version would be:
“Performed dressing change, cleaned wound with NS and gauze, applied calcium alginate, covered with ABD, secured with silk tape. Patient tolerated well.”
This revision provides a clear picture of every step of the procedure and explains use of all materials. (Note: even further explanation may be necessary to describe wound status and any changes or doctor notifications.)
Always try to remove personal emotions and opinions from the writing you do. Place yourself in a dispassionate mindset and record information, not feelings, hunches, or viewpoints.
Example: “Patient acting crazy.”
This statement relies on the nurse’s subjective opinion of the patient’s mental state. A better version would be:
“Patient pacing back and forth, breathing fast, clenching fists, yelling ‘Don’t touch me!’ repeatedly.”
This provides a clear picture of what actually happened during the incident, allowing the reader to draw his or her own conclusions.
Remember Your Critical Audience
Litigation and auditing are a fact of life in the medical field, and chances are good that readers of your writing will be actively looking for mistakes or inconsistencies. Scrupulous charting and reporting is the best way to satisfy such readers.
Examples: “Did dressing change.” “Patient acting crazy.”
Both of the examples in the above points could be used by a critical audience to have cause for correction or could be used negatively against you in court. The phrase “Did dressing change” details no necessity for specific materials, leaves room for doubt as to compliance with doctor-ordered treatments, and can provide space for accusations from expert witnesses. Writing “Patient acting crazy,” without quantifying statements and description of your actions, can be grounds for charges of negligence. Either one of these cases, in an extreme scenario, could be grounds for you to lose your license.