The nursing profession demands adept and precise writing skills. It involves accurately filling out reports and charts, as well as documenting interactions with doctors and patients in an unbiased manner. The following guidelines aim to help you become familiar with this type of writing both during your education and in your nursing career.
Three General Rules
1. Be Precise:
While it may appear obvious, precision is crucial not only in areas like medication administration and treatment procedures but also in accurately reporting sequences of events, doctor’s orders, and patient concerns. Maintaining precision protects you from scrutiny.
Incorrect – “Did dressing change.”
Correct – “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 and detailed account of each step of the procedure and the materials used. (Note: Additional information may be required to describe wound status, changes, or doctor notifications.)
2. Be Objective:
Strive to eliminate personal emotions and opinions from your writing. Approach the task with a dispassionate mindset, focusing on recording information rather than feelings, hunches, or viewpoints.
Incorrect – “Patient acting crazy.”
Correct – “Patient pacing back and forth, breathing fast, clenching fists, yelling ‘Don’t touch me!’ repeatedly.”
This offers an objective description of the incident, enabling readers to draw their conclusions without subjective bias.
3. Remember Your Critical Audience:
In the medical field, litigation and auditing are common occurrences, and your writing will likely be closely examined for errors or inconsistencies. Diligent charting and reporting are essential to satisfy such critical readers.
Incorrect – “Did dressing change.” “Patient acting crazy.”
Both of the examples above could be used by a critical audience to demand correction or be used against you in court. The phrase “Did dressing change” lacks specificity regarding materials used, leaves room for doubt about compliance with doctor-ordered treatments, and can lead to accusations from expert witnesses. Writing “Patient acting crazy,” without providing quantifying statements and descriptions of your actions, may result in charges of negligence. In an extreme scenario, either of these cases could jeopardize your nursing license.