Guide to Writing Nursing Clinical Write-ups Course: Nursing Processes and Skills II

Professors: Ohrt, Shostrom

*This guide for writing nursing clinical write-ups was written by Bethany Babovec, a former Writing Center Consultant, in fulfillment of an assignment for Topics in Composition, the Writing Center staff development course.

Further instructions on assignment: The expected method for gathering data for the paper includes providing appropriate patient care through holism (addressing the entire patient), balancing subjective and objective data, and organizing the paper according to the Nursing department model and based on NANDA standards. The purpose of this assignment is to gain a greater knowledge of patient care and practice documentation. Past student have acknowledged that the skills learned while writing these papers are recycled again and again in later courses. Any questions that are not answered in the syllabus or on this webpage may be asked during lecture or during an appointment with the clinical instructor. Changes throughout the semester will be announced during lecture or written on individual papers.

Other additional materials: Is it expected that each student will use their copy of The Health and Physical Assessment book and their NANDA Nursing Diagnosis book in addition to the HAT (Health Assessment Tool) provided in the syllabus. Mosby's Medical Dictionary and many other medical textbooks are available in the library. These additional books should be used to clarify and eliminate errors in documentation.

Guidelines for grading: This is a Pass/Fail course. Grading is based on the student's knowledge shown through correct usage of the HAT. Organization of the paper is also important. It is expected that each week the write-up will become more specific and a better example of nursing documentation. Grading will affect this gradual improvement. Clarity will be explained during lecture and in individual side-notes from the instructor. An evaluation of clinical ability, teaching, and writing will be done at mid-term and at the end of the year.

Common issues: Styles: The data gained from interviews should be in a list format. Stressor development paragraphs should be in a narrative style. The NANDA (high priority and assessment) diagnosis should be exacting and specific following the Nurses Association guidelines. Students are expected to use proper medical terms (learned in lecture and reading), grammar, and spelling.

The most common concerns with student's writing involve:

1. Lack of organization, because this is a new style of writing. Always include the data (history) first, next the highest priority problem, and finally a label (NANDA diagnosis).
2. Incorrect use of medical terminology.
3. Communication through writing should be clear and succinct.
4. Understating the paper guidelines.
5. Mistakes involving description of stressor development.

The intended audience for the writing: The papers should be appropriate for reading by all other health care providers and nursing instructors.

Useful suggestions from other sources:

• In 1910, Lewis wrote: "It is one of the most important duties of a modern nurse to be able to give an intelligent (written) report of a case; but it is also that duty which a nurse is longest in acquiring, and which requires, perhaps, more hard work to attain perfection in than anything else which a nurse has to do."

  Lewis, P (1910) Nursing: Its Theory and Practice. 12th ed. The Scientific Press, London 6-8. Also found in Allen, M (1992) Blunders found in nursing documentation. British Journal of Nursing 7, 19.
  
  
  
  

• "Good documentation is accurate, precise, comprehensive, legible, objective, timely, and unaltered."

  "Get in the habit of recording observations, treatments and events as soon as possible after you observe them perform them or hear them."

  "Some providers use cheat sheets, such as notebooks, 3X5" cards, or pieces of tape placed on their pant let to take notes during an [emergency] and later transfer the information to their reports."

  "Before submitting data, always proofread the documentation."

  "Review past reports... allowing you to examine documentation strategies, evaluate patient care techniques and learn from the experiences of veteran providers."

  Munger, R (2001) On the write track: 20 strategies to prepare clear and accurate documentation. JEMS 26, 1 (Jan '01)
  
  
  
  

• "The bottom like difference on whether an [insurance] claim can or will be paid rests solely on the caregiver's record of the event."

  "A complete, well-written record provides statistical data for quality assurance, assists companies in monitoring the use of personnel and supplies, and - most importantly - provides an avenue of protection against frivolous lawsuits and costly litigation."

  "The reader needs to know those things you saw, heard, or felt that led you to believe medical intervention was necessary and demonstrate that the treatment you rendered was reasonable and prudent."

  Murnane, J (2000) Document this... JEMS 25, 1 (Jan '00)