Writing Skills
Nurses need to be able to read and write in the language of the country in which they are providing care. In the United States that language is English. Throughout the country, however, there may be other predominant languages such as Spanish, French, or a variety of Native American and Asian dialects and languages. In most instances, although these may be the languages of the patients, the official language of the facility will be English. To practice as a nurse in the United States, you must be able to read and write in English.
It is important to remember that the health care record is a legal document and that documentation is not optional. Nor is it trivial and unimportant. The cliché about no job being done until the paperwork is completed is perhaps more true of health care than almost any other profession.
Your documentation reflects the care you have or have not provided to your patient and is your only legal proof that you did or did not do something. Your documentation needs to be as important as the care you provide. Often, nurses feel that the hands-on care is all that is important and that the documentation is a waste of time. This is never the case. These responsibilities should carry equal importance at all times, because your documentation becomes a part of the patient's medical record.
The skill with which you write about your assessment, intervention, and the patients' outcomes will reflect on the quality of the hands-on care you provide. Your records must be clear, concise, complete, and accurate. Other health care providers will rely on this information to make decisions about the patient's care and needs.
Your writing skills need to be proficient enough to provide a reflection of your observations, which will include your assessment, your identification of problems and issues, your plan and interventions, and an evaluation of the outcomes. Terms need to be specific and factual, not vague and nondescript.
You need to represent the five senses to the reader. If a wound is ugly and disgusting that no doubt conveys a message, but does not accurately describe the wound. The following gives a much clearer description of the wound: “The old dressing was removed. The R hip wound is now 3 cm. by 4 cm. by 0.5 cm. There is 1 cm. strip of yellow slough along the entire right side that is well adhered and pink granulation tissue around the outer edges of the other three sides. There is a slight odor emanating from the slough, but the old dressing has no odor. There is a small amount of serosanguineous drainage on the inner aspect of the dressing. The patient is afebrile and experiences only slight (0–2/10) pain during the dressing change.” You would go on to explain the new dressing procedure and sign your note with your name, credentials, date, and time, according to your facility's policies.
