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Writing as a Professional Nurse

Summary:

These resources will help you write on the job and in the classes you will take to become a nurse.

"Writing as a Professional Nurse" provides three general, though important, rules working nurses should keep in mind while writing reports and charts and while communicating with doctors and patients.

"Writing in the Field" discusses three examples of writing tasks nurses perform: flowcharts, careplans, and narratives.

"List of Nursing Resources" provides links to Purdue OWL resources that both nurses and nursing students might find helpful while writing for work or school. Each link provides a brief description of the resource and how and why it will help nurses and students with their writing tasks.

Contributors:J. Case Tompkins, Eden Tompkins, Elizabeth Angeli
Last Edited: 2012-12-20 09:43:17

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

Be Precise

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.)

Be Objective

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.

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