Writing Found in the Nursing Profession
A nurse's job of medical documentation often goes unnoticed, but should it?
Starting this past August, every Tuesday from 11:30 to 3:30, you could find me in Lerner Tower 5 at University Hospital. As a first year student nurse, we are assigned to weekly clinicals to begin our experience of being in the hospital. Being able to have the first hand experience of working with the patients from the first week really gives us a sense if this is the right fit for a future profession. It is also advantageous because we are able to work side by side with knowledgeable and experienced nurses who really know what they’re doing.
The usual routine consists of every student being assigned to a patient and receiving a brief background of their admission diagnosis and their current status. After this we disperse to go meet our patients and get acquainted with their medical information. All this information can be found in different forms of documentation.
Outside of every patient room is a box on the wall which holds a binder filled with charts and notes filled out primarily by nurses. When a new nurse comes on shift it is key that they are updated of the patient’s current progress and plan of care which is left behind by the previous nurse. Some of these papers include flow charts that are updated every hour to four hours which contain information such as vital sign data, intake and output measurements, and routine check ups, such as making sure the call light is in reach, or if the patient has been helped to the bathroom if they need assistance. Although the task of writing all of this down may seem insignificant and tedious, it is extremely important because it is a nurse’s job to make sure that the patient is looked after appropriately down to the smallest detail. It is also important because patients are often transported to another floor to have tests run on them so they will be handed over to another caretaker. It is crucial for the other doctors to have all the information they need to know that they would not know if it were not for the documentations left by the nurses.
As student nurses, we are still trying to learn all the different methods, techniques, and abbreviations used during different note processes. To practice these skills we are given clinical worksheets ( Download file ) to fill out with our assigned patient’s medical information. The first page teaches us how to identify key information and how to find it in the charts available. The second page is another learning tool to help us reflect on the documenting we have done and what we have learned from it. By doing these worksheets every week, we get into the habit of recording detailed information and gets us familiar with the actual charts used in the hospital. It also allows us to begin seeing and using the abbreviations that are commonly used. With symbols such as ADLs, D/C, gtt, NPO, and prn, it began as a foreign language to me. However, after the first few months, I am beginning to recognize different abbreviations when I see them and even begin to use them myself in my documenting.
Although this aspect of a nurse’s job often goes unnoticed, it does not take away from its importance. Even after a patient is discharged, all of these documents are kept on file so if they are ever readmitted to UH or any other hospital, their past medical history is accessible. Even though this is not scholarly writing, it is just as important and deserves just as much respect as any other writing for it is what keeps hospitals running successfully.
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