Writing in Nursing
Writing is all about the patients...
In the professional nursing role, writing is all about the patients. Writing skills are necessary for a nurse to have in order to communicate information on the patient’s health record. Writing allows other nurses or doctors seeing the patient to know what has constantly been going on with that particular patient. It is very important that nurses are able to summarize while still having a very detailed report. As nursing students we are already beginning to chart information on our patients.
As first year nursing students, we have clinicals for four hours on one day a week. In these clinicals we are assigned one patient who we must look after. Being first year students there is not a whole lot we are able to do, but we chart on what the patient is doing. In most patients we must chart their intake and output; we need to know everything they put in their system and how much is coming out. We also must chart how they are positioned in bed. We need to know whether they are lying on their back, side, or sitting up in a chair. As nurses we also chart when we check on the patient which is done every hour. All of this is very important in maintaining a constant record of the patient not only to know if they are getting better or worse but it lets the next nurse coming on shift know about the patient.
There is also a lot of other documentation nurses do on their patient’s status that we are only practicing right now as first year nursing students. There are different kinds of “notes” that address patient problems and nursing diagnosis. The North American Diagnosis Association (NANDA) defines nursing diagnosis as “A clinical judgment about individual, family, or community responses to actual or potential health/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (Craven & Hirnle). The SOAP note is the most used today and is what we as nursing students practice each week. The SOAP note stands for Subjective data, Objective date, Assessment, and Plan. In this note you first collect subjective and objective data on your patient; what they patient is telling you and how they are acting. Then you assess the patient in what is called a nursing diagnosis, as described before. Last you come up with a plan. The plan is based on goals of the patient and of the nurse; it is what is going to happen. SOAP notes can be hard to learn at first; which is why we practice them in the first year of nursing.
Writing is very important in the professional nursing role and allows nurses to take care of their patients to the best of their ability. Nurses must have the ability to summarize data and choose what is important to document. Nursing students start charting in the first year and continue to chart throughout the four years. Nursing documentation can be hard to learn and comes easier with experience.
Information on documentation:
Craven, Ruth F., and Constance J. Hirnle. Fundamentals of Nursing. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2003.
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