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.
Writing in the Field
Writing in the Field: The Three Kinds of Charting
Most charting completed by nurses falls into one of three categories: 1) flowcharts; 2) careplans; and 3) narratives. Individual employers require different amounts of charting in these areas, (insert example here). The guidelines below are intended to be broad enough to cover many different levels of charting while still providing useful suggestions.
Although flowcharts are a part of nearly every medical service provider’s record keeping, the systems themselves are different enough between companies, and the skills required far enough from the writing process that this aspect of charting will not be covered here.
The careplan consists of three parts: 1) definition of the problem; 2) interventions and/or solutions; and 3) evaluation of the relative success of the interventions and solutions.
Nursing diagnoses are NOT medical diagnoses.
The diagnosis given by a doctor and the one acted on by a nurse are two different things. Example: A medical diagnosis is “Diabetes Mellitus,” while a related nursing diagnosis would be “risk for unstable blood glucose.” The first example is the doctor’s diagnosis of the patient, the second suggests a course of action to the nurse; you must work to reduce the risk.
Interventions and solutions must be specific to each patient.
Patient age, relative health, complicating factors and recovery range must all be considered when devising new interventions. Example: “Patient to check blood sugar 4 times, daily.” This may work for many patients, but if the patient is unable to check their own blood sugar (patient under the age of 5, patient physically impaired, patient has Alzheimer’s), this intervention is unrealistic and must be changed.
Evaluations must be measurable.
When writing the evaluation you must include a definite time frame and some measurable quantity to determine effectiveness. Example: “Patient will maintain blood-sugar levels between 80 and 120 x 2 weeks.” This provides both a measurable goal and a time frame for determining success.
Narratives are an important part of nursing communication and important components of capturing a patient's history and treatment.
Use only standard abbreviations.
Different facilities and even licensing agencies have standard lists of abbreviations. Make sure you know these standard abbreviations and resist the impulse to come up with your own, even if the meaning of the abbreviation seems obvious to you. Deviation from those accepted forms can cause confusion in your narrative and can even get you in legal trouble.
Do not use the first person.
In narrative charting, avoid the use of “I” and “me.” Instead of “I observed . . .” use “This nurse observed . . .” “I change the dressing daily,” becomes “Nursing changes the dressing daily.” This helps to maintain the impersonal tone discussed above.
Record communication with others.
Nursing never occurs in a vacuum. Your communications with doctors, therapists, other nurses, patients and their families regarding the patient’s health should be noted in your narrative, especially if such conversations result in or are pursuant to changes in patient care. Recording this communication allows readers of your narrative to track changes and establish clear lines of cause and effect.
List of Nursing Resources on the Purdue OWL
As a nursing student, you will write different types of texts, such as research papers and group presentations. All of this writing has common characteristics: to be concise, evidence-based, supported by credible and appropriate research, to be professional, and to follow APA style. This section offers resources that are designed to help nursing students with these and other writing concerns.
American Psychological Association (APA)
APA is used in scientific and social scientific disciplines, including nursing, and standardizes research and citation formats. These links provide information for APA style, with the first link offering an overview of APA style and the second providing specific APA rules and sample APA papers.
APA Paper Sample
This sample shows you how to write and format a nursing research paper in APA.
The Rhetorical Situation
This PowerPoint presentation will help you understand the importance of the context in which you write. There are many factors that influence your writing: you, the writer; your purpose; your audience; your context; and the culture surrounding the context. For example, you will write differently for your professors than you will for your patients. Their varying education levels and different situations, or context, will cause you to use different language and present your topic differently.
This resource will help you with one important part of the rhetorical situation: analyzing your audience and tailoring your writing to fit your audience’s needs. There is also a handout available on this page with a chart to help you with your audience analysis.
Writing Scientific Abstracts
This PowerPoint presentation discusses the importance of writing abstracts and offers tools on how to write them. Abstracts allow you to present information in a clear, concise manner and are part of writing in APA style.
Conducting Primary Research
Primary research is an important component while writing as a nursing student. It allows you to support your argument, or thesis statement, with evidence; this, in turn, creates ethos, or credibility, for you as an author. This link offers many resources about primary research, including how to get started and how to conduct the various kinds of primary research.
Conducting an Interview
This PowerPoint presentation discusses the steps involved in conducting an interview as part of primary research. You may be asked to conduct an interview with clinical nurses, patients, or physicians as part of a writing assignment or research paper. Consult this PowerPoint before contacting your interviewee because it offers tips for how to contact him or her.
Database Research Tutorial from the Purdue Library
Engaging in secondary research, or research that is gathered from existing research performed and published by another author, is an essential part of writing as a nursing student. Using databases is one way to collect information, and this resource links to the Purdue Library’s tutorial on how to use databases.
Searching the World Wide Web
The Internet is a convenient and useful way to gather information; however, nursing professors expect their students to perform research that goes beyond a Google search. This PowerPoint presentation offers strategies for conducting Internet research, and it explains components of using the Internet you may not be familiar with, for example, the visible and invisible web. Use this PowerPoint presentation in conjunction with the database research tutorial for a good overview of how to conduct Internet research.
Evaluating Sources of Information
Not all sources of information are credible or reliable, and it is your job as a nursing student to be able to tell the difference. This resource offers different ways to decipher whether or not a source is credible.
Documenting Electronic Sources
When conducting secondary research, you might come across credible electronic sources that you would like to integrate into your writing. Documenting these sources properly is important because it builds your credibility as a writer, and it shows your readers, i.e., your nursing professors, that you have followed APA guidelines. This resource provides information and links to other resources that will help you properly document electronic sources.
Annotated bibliographies, a summary and/or evaluation of sources, can help you organize your research. This resource explains the purpose of annotated bibliographies and provides examples. There are examples for APA, MLA, and CMS on this page; be sure to follow the APA format, as each citation style differs.
Thesis: Establishing an Argument
This page explains the importance of a thesis and how you can create an effective statement. Thesis statements are important to your writing because they control the paper’s overall purpose. These statements are especially important for you as a nursing student because writing in nursing should be logical, organized, concise, and clear; having a strong thesis will help you achieve this type of writing.
Grammar, Mechanics, and a Brief Discussion about Revision
The Grammar and Mechanics section on the OWL will help you learn how to use correct language. Using correct grammar will help your ethos, i.e., it will build your credibility, and it makes your writing appear more professional. One way to help improve your grammar is by reviewing the pages within the grammar and mechanics section and by completing the grammar and mechanics exercises.
Another way to help correct grammar mistakes is by revising your writing. You can fix most of your grammar errors by reading your paper aloud before you turn it into your professor. Reading your paper aloud also offers you a chance to hear your writing, and you may find that some of the ideas you thought were clear are not as clear or organized as you hoped they would be.
Designing an Effective PowerPoint Presentation
PowerPoint presentations are a useful tool to use when delivering individual or group presentations. This PowerPoint presentation defines the basic elements of a PowerPoint slideshow and discusses how you can use these elements in effective and professional ways.
Personal statements are an important part of the application process for nursing school. This section of resources offers writing samples and information that will help guide you while writing the personal statement. While using these resources and writing your statement, keep in mind the specific application for which you writing, as different nursing schools ask for different types of personal statements, i.e., the applications may ask you to respond to different types of questions.
Résumés and Cover Letters
Résumés and cover letters are important documents traditionally created toward the end of your nursing education, though it never hurts to start creating them during the start of your education. Use these resources to help you create your résumé and cover letter. You also might find it useful to consult the rhetorical situation and audience analysis resources, as these resources will help you understand the context in which and for which you will create your résumé and cover letter.
Links to commonly used databases and sites:
Databases available through the Purdue Library website:
Academic Search Premier
Health Source: Nursing/Academic Edition